Spinal Biopsy Research Articles

Neurogenic calf amyotrophy with CK elevation by entrapment radiculopathy; clinical, radiological, and pathological analyses of 18 cases.

To characterize the clinical, radiological, and pathological manifestations of 18 cases showing neurogenic calf amyotrophy with creatine kinase (CK) elevation by entrapment radiculopathy (NCACKEER). We retrospectively reviewed and evaluated the medical records of patients who complained of weakness or atrophy of the calf muscles in our department between 2004 and 2019. We identified 18 cases fulfilling the proposed criteria of NCACKEER. We extracted neurological, laboratory, neurophysiological, and neuroradiological data from all cases. Moreover, we evaluated biopsy specimens from the gastrocnemius in four cases. Eighteen NCACKEER cases exhibited the characteristic findings that can discriminate previously known myopathies or polyneuropathies affecting distal legs. We noticed male predominance (72%) with an average age at diagnosis of 65.6years. Muscle weakness or atrophy was localized in the distal legs, with Achilles tendon reflexes absent in all cases. We observed elevated serum CK levels with a range from 237 to 2294IU/L. All electromyography (EMG) studies showed neurogenic changes in the affected muscles. Lumbar spinal MRI exhibited either spinal canal stenosis at various vertebral levels or intervertebral foraminal stenosis at L4/5 and L5/S1 in all cases with significant straightening spinal and sacral alignments. All muscle biopsy specimens showed findings of neurogenic muscular degeneration with no inflammatory infiltrations. Cases with higher CK elevation had more necrotic muscle fibers. We established the clinical characteristics of NCACKEER. Evaluations of serum CK level and skeletal muscle CT imaging are useful for screening, and lumbar spinal MRI, EMG and/or muscle biopsy are necessary for diagnostic confirmation.

Optimization of Intracranial Germinoma Treatment: Radiotherapy Alone with Reduced Volume and Dose

We investigated optimal management for intracranial germinoma, including target volume and dose of radiation therapy (RT) and the combination of RT and chemotherapy (CTx). We retrospectively evaluated 213 patients with intracranial germinoma treated between 1971 and 2017. Treatment policies changed as diagnostic techniques and clinical experience improved. In the 1980s, trial RT and tumor marker study were performed, and craniospinal irradiation was performed to treat patients with presumed germinoma. CTx was introduced in 1991, and RT volume was reduced in patients showing a complete response. In 2012, the policy was changed to a "reduced volume/dose RT alone" approach, involving a smaller target volume (the whole ventricle/whole brain for localized disease) without CTx. RT doses were gradually reduced to 36 Gy for primary tumors and 18 Gy for neuraxis. The median age was 16 years. In total, 118 and 95 patients had pathologically proven and presumed germinoma, respectively, and 151 and 62 patients had localized and multifocal or metastatic diseases, respectively. With a median follow-up of 141 months, the 10-year disease-free and overall survival rates were 91.6% and 95.6%, respectively. Recurrence rates were similar for patients receiving RT-only (9 of 137, 6.6%) and those receiving CTx + RT (4 of 73, 5.5%); all patients receiving CTx-only experienced recurrences (3 of 3, 100%). Rates were the highest in the focal RT group (10 of 29, 34.5%) but were relatively low in the whole ventricle/whole brain RT (3 of 51, 5.9%) and craniospinal irradiation groups (0 of 130, 0%). Infield failure occurred in 3 patients. Fourteen patients died of recurrence (n = 4), secondary malignancy (n = 4), CTx-related toxicity (n = 2), and others (n = 4). Among the 33 patients who received "reduced volume/dose RT alone" treatment, 2 (6.1%) experienced recurrence in the spinal cord and biopsy tract, respectively. The additional benefit of CTx in the treatment of intracranial germinoma seems minimal. An RT-only approach with reduced target volume and dose seems reasonable.

Hirayama disease – Early MRI diagnosis of subacute medullary ischemia: A case report

Background: Hirayama disease (HD) is a rare, benign, and self-limiting motor neuron disorder that results in selective motor impairment of the C7-T1 myotomes. It is characterized by progressive, unilateral, or bilateral asymmetric muscle atrophy of the distal upper extremities and myelopathy.Case Description: A 23-year-old male presented with bilateral atrophy of the thenar/hypothenar eminences/ interosseous muscles, plus left-hand weakness. The cervical MRI documented subacute ischemic damage of the distal cervical cord. To rule out a tumor and reduce questionable cord compression, the patient underwent a C5–C6 anterior cervical discectomy and fusion (ACDF) immediately followed by a laminectomy with durotomy and to obtain a spinal cord biopsy. When the histology confirmed focal cord ischemia consistent with HD, it was clear that both operations were unnecessary.Conclusion: Establishing the diagnosis of HD is based on clinical findings and MRI/flexion MR features which include the demonstration of an increased T2-weighted intramedullary cord signal, enlargement of the posterior epidural space, and segmental spinal cord atrophy. The presence of HD should be recognized as a “nonsurgical entity,” and conservative nonsurgical management should be employed.

The clinical utility of fluoroscopic versus CT guided percutaneous transpedicular core needle biopsy for spinal infections and tumours: a randomized trial

Biopsy is important to obtain microbiological and histopathological diagnosis in spine infections and tumors. To date, there have been no prospective randomized trials comparing fluoroscopic guided and computed tomography (CT) transpedicular biopsy techniques. The goal of this study was to evaluate the accuracy, safety, and diagnostic outcome of these two diagnostic techniques. To evaluate the accuracy, safety, and diagnostic outcome of fluoroscopic guided and CT transpedicular biopsy techniques. Prospective randomized trial. Sixty consecutive patients with clinical symptoms and radiological features suggestive of spinal infection or malignancy were recruited and randomized into fluoroscopic or CT guided spinal biopsy groups. Both groups were similar in terms of patient demographics, distribution of spinal infections and malignancy cases, and the level of biopsies. The primary outcome measure was diagnostic accuracy of both methods, determined based on true positive, true negative, false positive, and false negative biopsy findings. Secondary outcome measures included radiation exposure to patients and doctors, complications, and postbiopsy pain score. A transpedicular approach was performed with an 8G core biopsy needle. Specimens were sent for histopathological and microbiological examinations. Diagnosis was made based on biopsy results, clinical criteria and monitoring of disease progression during a 6-month follow up duration. Clinical criteria included presence of risk factors, level of inflammatory markers and magnetic resonance imaging findings. Radiation exposure to patients and doctors was measured with dosimeters. There was no significant difference between the diagnostic accuracy of fluoroscopic and CT guided spinal biopsy (p=0.67) or between the diagnostic accuracy of spinal infection and spinal tumor in both groups (p=0.402 for fluoroscopy group and p=0.223 for CT group). Radiation exposure to patients was approximately 26 times higher in the CT group. Radiation exposure to doctors in the CT group was approximately 2 times higher compared to the fluoroscopic group if a lead shield was not used. Lead shields significantly reduced radiation exposure to doctors anywhere from 2 to 8 times. No complications were observed for either group and the differences in postbiopsy pain scores were not significant. The accuracy, procedure time, complication rate and pain score for both groups were similar. However, radiation exposure to patients and doctors were significantly higher in the CT group without lead protection. With lead protection, radiation to doctors reduced significantly.

Central Nervous System Fungal Infection-Related Stroke: A Descriptive Study of Mold and Yeast-Associated Ischemic Stroke

Objective: Central nervous system (CNS) ischemic events caused by fungal infections are rare, and clinical characteristics of these ischemic events are largely unknown. The objective of this manuscript is to highlight characteristics of fungal-related strokes and describe possible mechanistic differences between CNS mold and yeast infection-related strokes. Methods: We report a single-center retrospective case series of all adult patients who presented with concurrent CNS fungal infection and stroke between 2010 and 2018. Patients believed to have a stroke etiology due to cardioembolic, atheroembolic, or strokes nontemporally associated with a CNS fungal infection and those with incomplete stroke workups were excluded from analysis. Results: Fourteen patients were identified with ischemic stroke and concurrent CNS fungal infection without other known ischemic stroke etiology. Eight patients had a CNS yeast infection, and 6 had a CNS mold infection. All patients presented with recurrent or progressive stroke symptoms. Six patients were immune-compromised. Four patients admitted to intravenous drug use. All yeast infections were identified by cerebrospinal fluid culture or immunologic studies while all but one of the mold infections required identification by tissue biopsy. Leptomeningeal enhancement was only associated with CNS yeast infections, while basal ganglia stroke was only associated with CNS mold infections. Conclusion: Ischemic stroke secondary to CNS fungal infections should be considered in patients with recurrent or progressive cryptogenic stroke, regardless of immune status and cerebrospinal fluid profile. CNS yeast and mold infections have slightly different stroke and laboratory characteristics and should have a distinct diagnostic method. Depending on clinical suspicion, a thorough diagnostic approach including spinal fluid analysis and biopsy should be considered.

Bulbocavernosus Reflex Monitoring During Intramedullary Conus Tumor Surgery

A T10 to L2 spinal cord tumor exploration and biopsy was performed with intraoperative neurophysiological monitoring (IONM) on a 75-year-old male diagnosed with an intradural intramedullary appearing spinal cord lesion with no other lesions in the central nervous system, chest, abdomen or pelvis.Intraoperative neurophysiology consisted of transcranial electrical motor evoked potentials (TCeMEPs), somatosensory evoked potentials (SSEPs), triggered and spontaneous electromyography (S-EMG, T-EMG), bulbocavernosus reflex (BCR) and train of four (TOF) monitoring. Loss of BCR responses during conus exposure and identification were resolved with multiple small pauses in manipulation throughout the procedure. T-EMG mapping aided in identification and avoiding the removal of nervous tissue.Postoperatively the patient experienced some mild weakness in his left foot and leg that correlated with a significant amplitude drop in the left abductor hallucis TCeMEP. By the following day, the patient was almost back to preoperative baseline. The patient’s bowel and bladder function were preserved, consistent with final BCR recordings. The patient was discharged to rehabilitation postoperatively. Pathology results indicated glioblastoma.This case study demonstrates the utility of a multimodality approach with bulbocavernosus reflex and urethral sphincter monitoring to optimize intraoperative data to the surgeon during conus tumor surgeries.

A retrospective audit of microbiological sampling for spondylodiscitis at the Royal Devon and Exeter Hospital (RD&E)

Introduction Spondylodiscitis is an increasingly diagnosed condition with significant morbidity and mortality. A key aspect of management is a protracted course of targeted antimicrobial therapy, ideally tailored to the organisms isolated from appropriate microbiological specimens in accordance with Infectious Diseases Society of America (IDSA) guidelines (2015). When consulted regarding possible discitis, we routinely recommend blood cultures and disc biopsy, particularly if blood cultures are negative. Method We undertook a retrospective audit of patients presenting over 6 years with a radiological diagnosis of discitis with the primary objective of determining the proportion of patients who had appropriate microbiological investigation either via blood culture or biopsy. Results 42 patients met the inclusion criteria. Blood cultures were positive with organisms likely to be the causative agent in 50% of patients. Of the 50% of patients with negative blood cultures, 57% went on to have a successful spinal biopsy. Biopsies proved positive in 75% of cases. 8 patients with negative blood cultures did not progress to biopsy at the time of diagnosis and four suffered some degree of harm. One of these patients failed empirical anti-staphylococcal therapy and later required spinal stabilization due to destruction of the spinal disc was proven to have pseudomonas infection at the time of the corrective surgery. Conclusion 19% of patients with discitis did not have appropriate disc sampling prior to commencement of antibiotic therapy. 50% of these suffered some degree of harm. This strengthens the case for recommending appropriate sampling prior to initiation of therapy, unless absolutely contraindicated.

Complete spinal cord injury following computed tomography-guided biopsy of the thoracic spine: A case report.

Computed tomography–guided spine biopsy is a routine procedure in diagnosing vertebral infection or tumor. Following a thoracic intervertebral disc biopsy for presumed osteodiscitis, a patient immediately presented with flaccid paralysis and loss of temperature and pinprick sensation below biopsy level, followed rapidly by complete sensation loss. There was no evidence of direct injury during the biopsy, and emergent post-biopsy magnetic resonance imaging revealed no cord signal abnormality or compression. Later magnetic resonance imaging demonstrated corresponding-level cord edema, presumed secondary to transient cord ischemia during the procedures. Despite frequent utility, authors recommend caution in utilization of computed tomography–guided spine biopsy.

Diagnostic yield and technical aspects of fluoroscopy-guided percutaneous transpedicular biopsy of the spine: A single-center retrospective analysis of outcomes and review of the literature.

Background:The technique of a percutaneous transpedicular biopsy of spinal lesions has been shown to be a useful alternative to paraspinal biopsy for vertebral body lesions in the thoracic and lumbosacral spine. Percutaneous vertebral biopsy is less invasive, cost-effective, and is suitable for patients with intractable back pain and vertebral body lesions that are detected with noninvasive imaging modalities.Objective:The purpose of this study was to establish the diagnostic utility and spectrum of fluoroscopy-guided percutaneous transpedicular biopsies of the thoracolumbar spine performed at our institution.Materials and Methods:This retrospective descriptive study to establish the diagnostic utility and spectrum of percutaneous fluroscopic guided transpedicular biopsy of lower thoracic and lumbar vertebral lesions has been performed on 42 patients in a tertiary care hospital between April 2017 and December 2019. There were 28 male patients and 14 female patients. The mean age was 48 years (range: 12–66 years). There were one 14 thoracic, 26 lumbar, and 2 sacral biopsy specimens. The lesion level was determined under fluoroscopy. Biopsy was taken with a trephine needle under local anesthesia. Accuracy and effectiveness of the technique were analyzed on histopathologic confirmation.Results:The fluoroscopic guided percutaneous transpedicular spine biopsies of 42 patients with spinal pathology were performed through the posterior transpedicular approach percutaneously. Of the 42 patients, 28 were male (66.7%) and 14 were female (33.3%). Vertebral involvement was observed to be more in the lower thoracic region (26.2%), followed by the upper dorsal region (7.1%), L1 (23.6%), L2 (6.4%), L3 (14.6%), L5 (17.3%), and sacrum (4.8%). There were 21 cases with tumor etiology (14 metastasis, 2 malignant round cell tumor, 2 multiple myeloma, and 3 lymphomas), 14 tuberculosis (TB), 4 osteomyelitis, 2 inflammatory, and 1 isolated compression fractures. Twelve patients of the 14 diagnosed cases who were diagnosed with TB on histopathology had positive TB culture and sensitivity pattern.Conclusion:Percutaneous transpedicular fluoroscopy-guided biopsy with a Jamshidi trocar with an internal diameter of 3.1 mm is a simple, safe, and reliable method for the etiological diagnosis of vertebral lesions. The use of this technique, however, is dependent on the accurate placement of the trocar and on close qualified interdisciplinary clinical cooperation. This minimally invasive technique is simple, safe, and effective in the diagnosis of malignant and infective lesions.

18F-FDG PET/CT as a modality for the evaluation of persisting raised infective markers in patients with spinal tuberculosis

Aims: The aim of the study was to investigate the differences in participant characteristics between positive and negative, positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) activity at the spinal tuberculosis (TB) site following 12 months of the appropriate chemotherapy therapy for spinal TB. A secondary aim of the study was to determine whether erythrocyte sedimentation rate (ESR) levels could be used as a reliable marker of TB activity and/or treatment success of spinal TB, especially in a high HIV-positive population. Patients and methods: All patients who were treated for spinal TB and underwent an 18F-FDG PET/CT scan were considered for inclusion. PET/CT positive patients underwent a spinal biopsy which was sent for microscopy, Gram staining, Gene Xpert (GXP) polymerase chain reaction (PCR) and histology. Patients in the PET/CT positive group underwent a repeat MRI scan and biopsy at the completion of treatment to investigate the potential presence of resistance or ongoing active spinal TB. Results: A total of 18 patients were included in the study: five patients were allocated to the PET/CT positive group and 13 to the PET/CT negative group. The PET/CT negative group was significantly older (p=0.016) and had significantly fewer TB-infected vertebrae (p=0.010) than the PET/CT positive group. Two patients, one in each group, were found to have drug-resistant spinal TB. At the 12-month follow-up visit, two patients (40%) in the PET/CT positive group and three patients (30%) in the PET/CT negative group were still complaining of back pain. All smear microscopy results of the PET/CT positive patients who underwent a repeat biopsy were negative after the conclusion of treatment; culture results (n=4/4) were also negative. GXP PCR results were positive in four and negative in one case. Only one of four samples showed classic TB signs on histology. Conclusion: This study is the first to report on biopsies done from a PET/CT positive site, after 12 months of anti-tubercular treatment. It is not unlikely that PET/CT is over-sensitive and can show metabolic activity in areas of sterile inflammation, and future studies are necessary to evaluate this. Level of evidence: Level 3

Infective Spondylodiscitis: A Comparative Analysis of Magnetic Resonance Imaging Findings with Etiology

Introduction: Spondylodiscitis in the Indian population is mostly tubercular and pyogenic. Gadolinium-enhanced magnetic resonance imaging (MRI) is currently most suited for radiological evaluation of the spine in patients with suspected vertebral osteomyelitis. Histology is highly sensitive in detecting the presence or absence of spondylodiscitis but fails in addressing the causative organism. The identification of organism is mainly through microbiological methods such as culture and tuberculosis (TB) polymerase chain reaction. The use of both pathologic examination and culture of the specimen along with imaging findings is paramount in establishing the diagnosis. Methodology: We performed prospective analysis of MR images obtained from patients with suspected spondylodiscitis who have undergone spinal biopsy for confirmation of diagnosis. T2- and T1-weighted images with and without contrast enhancement were subjected to assessment in coronal, axial, and sagittal planes. The sample obtained from biopsy was sent for microbiological and pathological analyses. Based on the final results, MRI findings and histopathological findings were correlated. Results: Out of 45 studied cases, 35 were confirmed to be infective spondylodiscitis, 5 were degenerative disc disease, 1 lymphoma, and 4 metastatic disease of the spine. Out of 35 confirmed cases, 17 (48.6%) were caused by TB and 18 (51.4%) by pyogenic organisms. The sensitivity and specificity of MRI for correctly diagnosing tuberculous spondylodiscitis were 70.6% and 77.8%, respectively, whereas the sensitivity and specificity of MRI for correctly diagnosing pyogenic spondylodiscitis were 44.4% and 85.2%, respectively. The statistically significant features specific for tuberculous spondylodiscitis for MRI were thin and smooth abscess wall, involvement of >2 vertebral bodies (52.9% in tuberculous vs. 44.4% in pyogenic), skip lesions (23.5% in tuberculous vs. 0% in pyogenic), and cold abscess (17.6% in tuberculous vs. 0% in pyogenic). Conclusion: It has been found that MRI is highly sensitive in detecting infective spondylodiscitis and has been widely accepted as the imaging modality of choice for the same. Although many imaging features have been identified to differentiate pyogenic and tuberculous etiologies, due to overlapping of these features, the sensitivity of MRI to conclusively diagnose the etiology needs further studies.

Percutaneous Vertebroplasty: A History of Procedure, Technology, Culture, Specialty, and Economics.

Percutaneous vertebroplasty (VP) progressed from a virtually unknown procedure to one performed on hundreds of thousands of patients annually. The development of VP provides a historically exciting case study into a rapidly adopted procedure. VP was the synthesis of information gained from spinal biopsy developments, the inception of biomaterials used in medicine, and the unique health care climate in France during the 1980s. It was designed as a revolutionary technique to treat vertebral body fractures with minimal side effects and was rapidly adopted and marketed in the United States. The impact of percutaneous vertebroplasty on spine surgery was profound.

Optimization of intracranial germinoma treatment: A single institution experience with 213 patients supports radiotherapy alone with reduced volume and dose

Abstract Purpose We investigated optimal management for intracranial germinoma, including target volume and dose of radiotherapy (RT) and the combination of RT and chemotherapy (CTx). Methods We retrospectively evaluated 213 patients with intracranial germinoma treated between 1971 and 2017. Treatment policies changed as diagnostic techniques and clinical experience improved. In the 1980s, trial RT and tumor marker study were performed, and craniospinal irradiation was performed to treat presumed germinoma. CTx was introduced in 1991, and RT volume was reduced in patients showing a complete response. In 2012, the policy was changed to a “reduced volume/dose RT alone” approach, involving a smaller target volume (the whole ventricle/whole brain for localized disease) without CTx. RT doses were gradually reduced to 36 Gy for primary tumors and 18 Gy for neuraxis. Results The median age was 16 years. In total, 118 and 95 patients had pathologically proven and presumed germinoma, respectively, and 151 and 62 patients had localized and multiple diseases, respectively. With a median follow-up of 141 months, the 10-year disease-free and overall survival rates were 91.6% and 95.6%, respectively. Recurrence rates were similar for patients receiving RT-only (9/137, 6.6%) and those receiving CTx+RT (4/73, 5.5%); all patients receiving CTx-only experienced recurrences (3/3, 100%). Rates were the highest in the focal RT group (10/29, 34.5%) but were relatively low in the whole ventricle/whole brain RT (3/51, 5.9%) and craniospinal irradiation groups (0/130, 0%). Infield failure occurred in three patients. Fourteen patients died of recurrence (n=4), secondary malignancy (n=4), CTx-related toxicity (n=2), and others (n=4). Among the 33 patients who received “reduced volume/dose RT alone” treatment, 2 (6.1%) experienced recurrence in the spinal cord and biopsy tract, respectively. Conclusion The additional benefit of CTx in the treatment of intracranial germinoma seems minimal. An RT-only approach with reduced target volume and dose seems reasonable.

Nerve root biopsy in intramedullary spinal cord lymphoma: Technical note and case report

BackgroundA case of primary lymphomatosis of the central nervous system, with involvement of the spinal cord and a spinal nerve root is described, where the diagnosis was confirmed by biopsy of the infiltrated nerve root rather than the conus medullaris. Case descriptionA 57-year-old male presented to our clinic due to new-onset left lower extremity weakness. Magnetic resonance imaging revealed an intramedullary enhancing lesion at the T12-L1 level, and a small area of enhancement in a nerve root at the L4 vertebral body level. Clinical, imaging and laboratory investigations showed no evidence of extraspinal lesions, and comprehensive studies including twice-repeated lumbar puncture cytology were non-diagnostic. The patient proceeded with L2-L5 laminectomy for nerve root biopsy. Under microscope view, the involved nerve root was successfully identified and resected. Pathology confirmed the diagnosis of neurolymphomatosis with large B-cell lymphoma. The patient received chemotherapy with complete tumor resolution, one year after surgery. ConclusionsPrimary involvement of the spinal cord in malignant lymphoma is rare. Accounting for the high risk of neurologic deficits after conus medullaris or spinal cord biopsy, we demonstrate that biopsy of the affected nerve root can be considered a safer candidate in clinically suitable cases.

Case Series of Pott’s Spine Diagnosed by ZN Stain and BacTec MGIT in a Tertiary Care Hospital

Introduction: Pott’s spine is a destructive form of tuberculosis and accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal Tuberculosis is most often missed due to inadequate sample and lack of clinical history. Most of the Extrapulmonary tuberculosis (EPTB) can be diagnosed by Ziehl Nelson stain (ZN) only, when clinically suspected samples are adequate and optimally stained. We are reporting four case series of spinal tuberculosis diagnosed by ZN stain and confirmed by Bactec MGIT Culture.
 Material & Methods: These four clinically suspected spinal biopsis were received for ZN stain and MTB culture by MGIT.
 Results: All the four spinal biopsies were found positive by ZN stain as well as by BacTec MGIT.All the four cases were HIV negative. ESR and CRP of all four cases were raised.
 Discussion & Conclusion: Spinal tuberculosis can be easily diagnosed by ZN stain in resource constraint lab. Despite its common occurrence and the high frequency of long-term morbidity, there are no straight forward guidelines for the diagnosis and treatment of spinal tuberculosis. Early diagnosis and prompt treatment is necessary to prevent permanent neurological disability and to minimize spinal deformity.

Pediatric spinal cord biopsy: A case series from a high-volume referral center

Pediatric patients presenting with intramedullary spinal cord lesions often require specific diagnoses to guide their treatment plans. Though results from magnetic resonance imaging and lumbar puncture may narrow the differential diagnosis, these tests cannot always provide a definitive diagnosis. In such cases, spinal cord biopsy may be undertaken to provide a specific histopathologic diagnosis for guiding treatment. Data from the adult population show 24% of spinal cord biopsies can be nondiagnostic and the procedure may carry a 21% complication rate. Therefore, spinal cord biopsy may portend a similar high risk-to-benefit ratio in the pediatric population. Here, we review spinal cord biopsy cases scheduled for diagnosis, and not debulking, at a high volume pediatric referral center during a seventeen-year period. We report our experience with five patients who met our inclusion criteria. Due to the rarity of the procedure, statistically significant factors associated with improved diagnostic yield or peri-operative complication could not be identified. A definitive diagnosis which guided the post-operative treatment plan was obtained in four of our five patients. None of our patients developed post-operative motor deficits. However, these patients were susceptible to the same risks of open spine surgery, such as wound infections and spinal deformities. Our case series shows that intramedullary spinal cord biopsies may provide tissue for obtaining histopatholgic diagnoses. However, the potential risks of complication, and the possibility of obtaining nondiagnostic tissue, should be discussed with patients, families and their medical treatment teams.

03:36 PM Abstract No. 203 Utility of repeat spinal biopsies for evaluation of clinically suspected persistent or recurrent osteomyelitis

03:36 PM Abstract No. 203 Utility of repeat spinal biopsies for evaluation of clinically suspected persistent or recurrent osteomyelitis

The role of histology in the diagnosis of spondylodiscitis: correlation with clinical and microbiological findings.

The aim of this study was to determine the diagnostic utility of histological analysis in spinal biopsies for spondylodiscitis (SD). Clinical features, radiology, results of microbiology, histology, and laboratory investigations in 50 suspected SD patients were evaluated. In 29 patients, the final (i.e. treatment-based) diagnosis was pyogenic SD; in seven patients, the final diagnosis was mycobacterial SD. In pyogenic SD, the neutrophil polymorph (NP) infiltrate was scored semi-quantitatively by determining the mean number of NPs per (×400) high-power field (HPF). Of the 29 pyogenic SD patients, 17 had positive microbiology and 21 positive histology (i.e. one or more NPs per HPF on average). All non-SD patients showed less than one NP per HPF. The presence of one or more NPs per HPF had a diagnostic sensitivity of 72.4%, specificity 100%, accuracy 100%, positive predictive value (PPV) 81.0%, and negative predictive value (NPV) 61.9%. Sensitivity, specificity, and accuracy were greater using the criterion of positive histology and/or microbiology than positive histology or microbiology alone. Granulomas were identified histologically in seven mycobacterial SD patients, and positive microbiology was detected in four. The diagnosis of pyogenic SD was more often confirmed by positive histology (one or more NPs per HPF on average) than by microbiology, although diagnostic sensitivity was greater when both histology and microbiology were positive. Cite this article: Bone Joint J 2019;101-B:246-252.

Features and risk factors for recurrence of intradural spinal tumors

Spinal cord tumors include a variety of nosological units and are classified according to their localization and histological type. The search for literature sources in the Pubmed, EMBASE and eLibrary databases demonstrated the absence of studies devoted to study of the features and risk factors for the recurrence of intradural spinal tumors. the purpose of this study was to reveal features and risk factors of recurrence of intradural spinal tumors after microneurosurgical resection. material and methods. The study included medical records of 196 patients with intradural extramedullary and intramedullary spinal tumors. The extent of microneurosurgical tumor resection, clinical efficacy of surgery, and risk factors for recurrence of intradural spinal cord tumors were been analyzed. results. Improvement in neurologic deficit after surgery was noted in 116 (59.1 %) cases, neurologic status remained the same in 47 (24.0 %) patients, and worsening of neurological deficit was observed in 33 (16.8 %) cases. Total microneurosurgical resection of intradural spinal tumors was performed in 140 (71.4 %) patients, subtotal resection in 22 (11.2 %) patients, partial resection in 25 (12.7 %) patients and spinal cord decompression or biopsy and/or its roots were performed in 9 (4.6 %) of patients. The likelihood of recurrence-free survival of patients with benign intradural spinal cord tumors was significantly higher than that of patients with malignant tumors (p<0.001). Benign tumors (χ2=34.7, p<0.05), thoracic and lumbosacral tumors (χ2=10.3, p<0.05), low degree of neurological deficit (χ2=31.5, p<0.05), absence of syringomyelia/syringobulbia signs (χ2=13,2, p<0,05), as well as extramedullary tumors (χ2=12,6, p<0.05) allowed us to perform total degree microneurosurgical resection. Malignant tumors (χ2=34.8, p<0.05), cervical and thoracic tumors (χ2=8,4, p<0,05), high degree of neurological deficit (χ2=12,9, p<0.05), partial resection, biopsy or decompression of neural structures (χ2=9.7, p<0.05) and intramedullary tumors statistically significantly increased the risk of their recurrence. conclusion. Histological pattern, tumor localization, preoperative clinical and neurological deficit according to the McCormick classification and the extent of surgery are significant risk factors for recurrence of intradural spinal tumors.

Clinical Features and Prognosis Factors of Spinal Tuberculosis in Northern Tunisia: A Case Series of 60 Patients

Spondylodiscitis is a common but potentially serious form of extra-pulmonary tuberculosis. Very few descriptions are known from Tunisia. We have conducted a retrospective study including 60 cases of spinal tuberculosis, performed over a period of 20 years (1996-2016). The diagnosis was retained on bacteriological, radiological and anatomopathologic evidence. Sixty cases including 31 women and 29 men of spinal tuberculosis were involved. The mean age was 54.4 ± 21.3 years. The delay from onset to diagnosis was 6 months (1-14). Lumbar region was the most common infection site (68%). The magnetic resonance imaging has confirmed spinal infection in all cases. The percutaneous image guided spinal biopsy was conclusive in 24/42 cases (57.1%). All patients were put under anti-tuberculosis treatment with total treatment duration of 14 months. Fourteen patients underwent surgical act. The outcome was favorable in 42 cases (7%). Advanced age ≥ 65 years (P = 0.026), radiological evidence of spinal cord compression (P = 0.033) or abscess (P = 0.024), hyperleucocytosis higher than 11,500 elements/mm3 (0.031), or fractures on bone imaging (P = 0.018) and vertebral deformity (P < 0.001) were strongly linked to a bad outcome. Early diagnosis and treatment onset may ensure better outcomes and reduce neurological complications and vertebral deformity.