Spinal infection: state of the art and management algorithm

Introduction

Spinal infection is a rare pathology although a concerning rising incidence has been observed in recent years. This increase might reflect a progressively more susceptible population but also the availability of increased diagnostic accuracy. Yet, even with improved diagnosis tools and procedures, the delay in diagnosis remains an important issue. This review aims to highlight the importance of a methodological attitude towards accurate and prompt diagnosis using an algorithm to aid on spinal infection management.

Methods

Appropriate literature on spinal infection was selected using databases from the US National Library of Medicine and the National Institutes of Health.

Results

Literature reveals that histopathological analysis of infected tissues is a paramount for diagnosis and must be performed routinely. Antibiotic therapy is transversal to both conservative and surgical approaches and must be initiated after etiological diagnosis. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and upon failure of conservative treatment.

Conclusions

A methodological assessment could lead to diagnosis effectiveness of spinal infection. Towards this, we present a management algorithm based on literature findings.     

强直性脊柱炎下颈椎骨折的临床回顾性分析

目的:探讨强直性脊柱炎下颈椎骨折的手术方式和疗效。方法:自2003年1月至2011年10月,对采用手术治疗(7例)和保守治疗(1例)的强直性脊柱炎下颈椎骨折患者进行回顾性分析,8例均为男性,年龄27～49岁,平均41岁。所有骨折经CT、MRI证实,其中6例骨折伴脊髓损伤症状。1例采用头颈胸支具保守治疗,其余7例手术治疗,手术方式包括单纯前路(5例)、单纯后路(1例)和联合前后路(1例);术后随访根据CT等影像学检查骨折融合情况,并根据Frankel分级的改变来评估脊髓损伤是否改善。结果:8例患者均获随访,时间4～38个月,平均18个月。7例患者获得骨性融合,无脊髓损伤患者(3例)术后随访仍无脊髓神经损伤,脊髓损伤患者(5例)术后随访各获得不同程度恢复。7例患者Frankel分级平均改善1级,1例患者骨折延迟愈合(随访中)。结论:强直性脊柱炎下颈椎骨折是一种相对特殊性的损伤,容易发生骨折移位损伤颈髓,应尽早采用手术治疗,手术方式则根据具体情况综合选择。     

经椎弓根截骨术治疗强直性脊柱炎继发颈胸段后凸畸形

目的评估后路经椎弓根截骨术(PSO)治疗强直性脊柱炎(AS)继发颈胸段后凸畸形的临床疗效。方法2009年1月—2015年3月,本院采用PSO治疗AS继发颈胸段后凸畸形患者7例。患者翻身至手术床之前,先放置石膏床于患者腹侧,并在患者颈胸段与石膏床的空隙处填充数个长方形棉垫。术中C6~T1后方截骨及经C7椎弓根椎体截骨完成后,由台下助手缓慢逐个抽取垫于患者和石膏床之间的长方形棉垫。待棉垫抽取完毕后,患者颈胸段的曲度在重力的作用下恢复至近似直线。然后采用体内弯棒技术进一步增加颈胸段前凸曲度。记录手术时间及术中出血量,用颈胸段(C_2~T_1)后凸Cobb角、颏眉角(CBVA)、C_2~T_1矢状面偏移距离(SVA)、疼痛视觉模拟量表(VAS)和健康调查量表(SF-36)评估临床疗效。结果 7例患者平均手术时间260 min,术中平均出血量1 571 m L,平均随访24.4个月,术前C_2~T_1 Cobb角平均为26.2°,末次随访时为-5.4°。术前CVBA平均为43.1°,术后改善至-0.9°。术前C_2~T_1 SVA平均为6.7 cm,术后改善至3.0 cm。末次随访时,患者的VAS评分由术前的85.0分改善至17.1分;SF-36躯体机能评分(PCS)由术前的20.7分改善至79.3分;SF-36精神机能评分(MCS)由术前的12.8分改善至81.6分。结论 PSO治疗AS继发颈胸段后凸畸形可以有效地恢复颈胸段的矢状位平衡,较好地改善患者前方视野受限、颏-胸畸形等症状,采用术中体内原位弯棒技术安全可靠。     

强直性脊柱炎骨髓间充质干细胞诱导Th17/Treg失衡

目的观察强直性脊柱炎(AS)患者外周血白介素(IL)-17A、IL-23水平及Th17/Treg比例,探讨骨髓间充质干细胞(BMSCs)与Th17/Treg体外相互作用,为研究AS发生机制提供理论依据。方法研究对象为48例活动期AS患者[实验组,男43例、女5例,年龄(26.2±5.2)岁,均为HLA-B27~+]和49例健康志愿者[对照组,男44例、女5例,年龄(25.9±4.8)岁,HLA-B27~+43例、HLA-B27~-6例]。ELISA检测外周血清中IL-17A及IL-23水平,流式细胞术检测外周血单个核细胞(PBMCs)中的CCR4~+CCR6~+Th细胞(Th17)及Treg细胞数量。分离健康志愿者的PBMCs,将PBMCs分别与AS患者及健康志愿者的BMSCs体外共培养72 h,收集PBMCs行流式细胞术检测,评价BMSCs与Th17/Treg体外的相互作用。结果实验组与对照组血清IL-17A及IL-23的表达水平相近(P0.05);实验组Th17细胞明显高于对照组(P0.05),而Treg细胞明显低于对照组(P0.05)。与健康志愿者BMSCs共培养72 h后的PBMCs中Th17较培养前轻度下降,Treg轻度上升,差异无统计学意义(P0.05);而与AS患者BMSCs共培养72 h的PBMCs中Th17较培养前及对照组均明显上升,Treg均明显下降,差异均有统计学意义(P0.05)。结论 AS患者PBMCs中Th17/Treg细胞亚群失衡。免疫抑制能力明显下降的BMSCs极可能通过诱导Th17/Treg失衡而在AS免疫发生机制中发挥重要作用。     

直接前方入路全髋关节置换术治疗强直性髋关节炎

目的探讨直接前方入路全髋关节置换术在治疗强直性髋关节炎中的临床效果。 方法回顾性分析2015年10月至2018年10月于福建省立医院行全髋关节置换术的强直性髋关节炎62例(66髋),纳入强直性脊柱炎合并髋关节炎行全髋关节置换的患者,排除脊柱畸形严重患者。根据手术入路分为直接前入路组和后外侧入路组,比较手术切口长度,术中出血量的差异,通过Harris髋关节功能评分、影像学评价两组患者手术效果。计量资料采用t检验,计数资料采用卡方检验。 结果直接前入路组和后外侧入路组在手术切口长度和术中出血量的差异无统计学意义(t＝1.346、1.272,均为P>0.05)。末次随访平均(25±11)个月,所有患者均解除疼痛,恢复髋关节活动功能。直接前入路组Harris评分术前平均(61±14)分,术后平均(97.8±2.9)分。后外侧入路组Harris评分术前平均(59.3±14.3)分,术后平均(97.4±3.3)分。两组组内术后Harris评分均明显高于术前(t＝14.229、14.729, P<0.001),但两组间差异无统计学意义(t ＝0.416, P>0.05)。术后X线片两组均无骨溶解及假体松动等征象,未发生术后并发症。 结论直接前方入路全髋关节置换治疗强直性髋关节炎的临床效果满意。     

动态监测骨代谢标志物在诊治强直性脊柱炎中的意义

目的通过对血清骨代谢指标的动态检测探讨其与强直性脊柱炎(AS)发生发展的相关性,为AS的诊断预后及治疗提供客观依据。方法根据AS患者骶髂关节的病损程度分早期、进展期、晚期3期,选择各50例门诊及住院患者。对照组选择年龄及性别相匹配的50名健康对照者,取患者晨起空腹血样,采用电化学发光免疫(ECLIA)及酶联免疫吸附试验(ELISA)检测骨代谢相关指标:甲状旁腺素(PTH),总Ⅰ型前胶原氨基末端(N端)前肽(tPINP),骨钙素N端中分子片段(N-MID OT),I型胶原C端肽(β-CTX),25-羟基维生素D3[25-(OH)D3],Ⅰ型胶原交联羧基末端肽(ICTP)。对3期各组间数据进行比较及相关分析。结果①AS组血清中NMID OT、25-(OH)D3低于健康对照组,β-CTX、ICTP高于健康对照组,组间比较差异均有统计学意义(P<0.01);tPINP、PTH浓度水平在AS患者组与健康对照组组间无显著差异性(P>0.05)。②AS晚期组血清中N-MID OT、25-(OH)D3低于早期组,组间比较差异具有统计学意义(P<0.05);晚期组β-CTX、ICTP浓度水平高于早期组,组间比较差异均有统计学意义(P<0.05);晚期组与早期组tPINP、PTH在组间差异无统计学意义(P>0.05);随着AS疾病的进展,血清中N-MID OT、25-(OH)D3浓度水平逐渐降低,β-CTX、ICTP浓度水平显著升高。结论血清骨代谢指标在分期不同的AS患者中存在异常,不同指标参与了AS的骨吸收及骨转换过程,可为AS的诊断预后及治疗提供客观依据。     

Cervical spine surgery in ankylosing spondylitis: Is the outcome good?

Summary Objective. To assess retrospectively, the outcome of cervical spine surgery in patients with ankylosing spondylitis (AS).Methods. A cross-sectional study of 3464 patients with identified AS, 19 patients of whom had cervical spine surgery. A self-administered questionnaire (including the use of 10 cm visual analogue scales, 0=none, 10=worst) assessing the complications of the surgery, patients' neck symptoms and post-surgery functional ability was sent to the 19 patients. Available casenotes and radiographs were reviewed. Results. The mean duration of follow-up was 10 years. One patient had two separate cervical spine operations. The types of surgery performed included cervical fusion (n=7), osteotomy (n=7) and laminectomy (n=6). Six patients had minor complications as a result of surgery. The majority of patients (93%) felt that their surgery had been successful. Most patients (81%) had a reduction in neck pain (mean pain score=3.1, SD 2.8) but increased neck stiffness (mean stiffness score=8.0, SD 2.9). Postoperative radiographs of 7 patients showed complete ankylosis of the cervical spine. Generally, few patients reported difficulty with reading/watching television (6%), sleep (19%) or driving (36%). A third of the patients were still in full time employment.Conclusions. About 1 in 200 patients with AS undergo cervical spine surgery. The surgery is often successful and complications are usually minor. Neck pain is often better after surgery and any remaining neck symptoms do not significantly affect the patient's sleep or functional activities. In this retrospective study, the long term outcome of cervical spine surgery in patients with AS appears to be good.The Arthritis and Rheumatism Council, the National Ankylosing Spondylitis Society, the Pilkington Trust and the Coates Trust. Dr Koh is supported by the Singapore government.     

The BASDAI-D--an instrument to defining disease status in ankylosing spondylitis and related diseases

OBJECTIVE: Translation and validation of the Bath Ankylosing Spondylitis Disease Activity Index ( BASDAI) for defining disease status in ankylosing spondylitis (AS) and related diseases. METHODS: The German version BASDAI-D was translated with only a few modifications. It contains six 10 cm horizontal visual analog scales to measure severity of fatigue, spinal and peripheral joint pain, tenderness and morning stiffness. A total of 318 patients with AS and other spondarthropathies completed the instrument at the beginning and at the end of their medical rehabilitation. Psychometric evaluation was performed separately for patients with AS corresponding to the modified New York Criteria ( SPA-NY, N=211) and for a second group of patients, which fulfilled the early diagnostic criteria for AS or the ESSG criteria of spondylarthropathies (Fd/Spond., N=86). RESULTS: SPA-NY: Factor analysis yielded one factor explaining 54.8% of variance. The sum score with a standard deviation of 1.94 is nearly symmetrical distributed with mean of 4.7. Reliability analysis yielded high internal consistency (Cronbach's alpha=0.83). Corrected item-total correlations are also high and are large ranging from 0.48 to 0.71. Concerning concordant validity the BASDAI-D showed a substantial correlation with the scale bodily pain of the SF 36 (r = -0.72). There are no correlations with objective clinical parameters. Furthermore the assessment of disease activity by the physician correlates significantly, albeit low with the BASDAI-D. Sensitivity to change yields effect sizes up to 0.60. Fd/Spond.: The results for this group are almost identical with SPA-NY (one factor explaining 53.8% variance, mean 4.6+/-1.75; corrected item-total correlations from 0.50 to 0.75; correlation with the scale bodily pain r = -0.62). Analysis for subgroups showed higher scores for women in both groups SPA-NY and Fd/Spond. CONCLUSION: BASDAI-D ist applicable for patients with AS and likewise for patients fulfilling the early diagnostic criteria for AS or the ESSG criteria of spondylarthropathies. In summary, BASDAID is reliable and valid. Because of its good acceptance and usability BASDAI-D is easy to use in research as well as in clinical practice.     

阿达木单抗治疗强直性脊柱炎致播散性结核病一例并文献复习

目的 探讨应用阿达木单克隆抗体(简称“单抗”)治疗强直性脊柱炎致播散性结核病的临床特点、诊治要点和治疗转归。 方法 回顾性分析福建省福州肺科医院2019年6月10日收治的1例应用阿达木单抗治疗强直性脊柱炎致播散性结核病的临床资料、诊治经过及随访情况,并进行文献复习。以“adalimumab”和“disseminated tuberculosis”为检索词对PubMed数据库进行检索,以“阿达木单抗”和“播散性结核病”为检索词通过万方数据库和中国知网对中文文献进行检索,检索时间截止到2019年9月,经过筛选剔除,共获取相关文献34篇,其中中文文献0篇,英文文献34篇。删去重复的文献并剔除可能为阿达木单抗以外的肿瘤坏死因子α(TNF-α)致播散性结核病及TNF-α致其他播散性疾病的报道,共筛选出具备详细病例资料的文献8篇,共获得8例患者,结合本研究收集的患者,对其临床特征、诊断和治疗情况进行分析。 结果 本例患者为男性,28岁。因“强直性脊柱炎”接受阿达木单抗治疗,治疗2个月后出现咳嗽、气促、腹胀、发热,入院后经胸部CT、胸膜活检及支气管镜等检查,诊断为“播散性结核病(双肺、右侧支气管、胸腔、腹腔、心包、纵隔淋巴结、锁骨上淋巴结、腹腔淋巴结、盆腔淋巴结、脾)”。给予“3H-R-Z-E/9H-R-E”方案治疗,辅以异烟肼支气管局部雾化吸入,行抗结核药物治疗后症状改善。治疗第5个月,CT复查提示“肺部病变减少,纵隔内部分淋巴结肿大较前缩小,增厚的支气管管壁较前变薄,管腔较前通畅,胸、腹腔积液明显吸收。截止到2019年12月,患者仍处于规则的抗结核药物治疗中。文献检索后获得8例患者,加上本例,共9例患者。其中,男3例,女6例;年龄9~75岁,平均年龄(50.44±25.19)岁。9例患者中,5例开始使用阿达木单抗治疗之前的结核病筛查试验结果为阴性,1例既往有抗结核治疗史,1例曾进行过预防性抗结核治疗,3例有与结核病患者的密切接触史。诊断明确行抗结核药物治疗后,5例患者转归良好。3例转归差,其中1例病情持续进展,并发消化道出血;1例颅内病灶持续进展;1例出现急性呼吸窘迫综合征,最终死亡。1例转归不明。 结论 阿达木单抗可致播散性结核病,准备接受阿达木单抗治疗的患者均应在用药前进行结核病筛查,治疗过程中应该警惕潜伏性结核感染转为活动性结核病及新发结核感染,停用阿达木单抗和及时行抗结核药物治疗是预后良好的关键。     

强直性脊柱炎患者运动指导方案的最佳证据总结

目的 总结强直性脊柱炎患者运动指导方案的最佳证据,为对强直性脊柱炎患者实施运动指导提供依据。方法 计算机系统检索UpToDate、BMJ最佳临床实践、OVID、CINAHL、Cochrane Library、Embase、PubMed、Scopus、中国知网、万方数据库、维普数据库、中国生物医学文献数据库、医脉通等指南网及专业协会网站和数据库中关于强直性脊柱炎患者运动方案的指南、系统评价、Meta分析、专家共识、证据总结、最佳临床实践等,检索时限为2012年1月1日—2022年1月1日,由2名护士独立对文献进行筛选、质量评价、提取最佳证据并分级,总结运动指导方案的最佳证据。结果 共纳入文献16篇,包括指南1篇、系统评价6篇、Meta分析4篇、专家共识5篇,总结出运动指导方案的最佳证据包括运动前评估、运动适用范围、不同疾病阶段分期的运动类型、运动项目内容（项目、内容、运动强度、频率、周期）、监督方式、运动监测指标、运动风险评估、注意事项共8个方面,39条证据。结论 该研究总结的强直性脊柱炎患者运动指导方案的最佳证据,规范了强直性脊柱炎患者康复运动的理论、实践,形成科学、规范、基于最佳证据...