Pyogenic osteomyelitis of the spine in the elderly: three cases of a synchronous non-axial infection by a different pathogen

STUDY DESIGN: A retrospective chart review of patients over 65 years of age treated at the Spine Care Unit for pyogenic vertebral osteomyelitis. OBJECTIVES: To assess the reliability of peripheral blood, urine and sputum cultures in the treatment of pyogenic vertebral osteomyelitis in the elderly. SETTING: Study performed at the Spine Care Unit, Meir Hospital, Kfar-Saba, Israel. METHODS: The Meir Hospital records were searched for patients over 65 years of age, treated at the Spine Care Unit for pyogenic vertebral osteomyelitis. Charts, culture results and imaging studies were reviewed. A medline literature search was performed to survey the literature regarding pyogenic vertebral osteomyelitis in the elderly with emphasis on diagnostic imaging modalities and surgical treatment. RESULTS: Three patients were identified with concurrent peripheral infection by a different organism than the organism causing the vertebral osteomyelitis. Delay in correct diagnosis led to neurologic impairment in all patients and surgical treatment was performed in all three to drain the epidural abscess, decompress the spinal cord and obtain direct tissue culture. Following decompression and epidural abscess evacuation, one patient has functionally recovered and was ambulating with a cane, two patients did not recover and remained paraparetic and ambulate in a wheelchair. CONCLUSIONS: Pyogenic vertebral osteomyelitis in the elderly can be caused by a different pathogen than that isolated from blood, sputum or urine cultures. In the elderly, a biopsy of the vertebral lesion should be obtained for susceptibility studies prior to conservative treatment with bracing and intravenous antibiotics.     

Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients

The purpose of this study was to assess and compare the outcome of surgical decompression for spinal stenosis in diabetic and non-diabetic elderly patients. This is a retrospective chart analysis conducted in a university affiliated referral hospital. The participants were consecutive patients, age 65 and older, undergoing laminectomy for spinal stenosis during 1990–2000. We assessed patients clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients satisfaction, the need for repeated surgery, and overall mortality. A total number of 62 elderly diabetic group (DG) patients undergoing decompression surgery for spinal stenosis were compared with a sex and age-matched non-diabetic control group (CG) at baseline, and a mean of 40.3 months thereafter. We found that the DG patients had more pain (p=0.042), and suffered more frequently from neurogenic claudication (p=0.0018), motor weakness (p=0.021) and numbness of the affected limb (p=0.0069) than the CG patients. Nocturnal pain was reported in 24% of the DG patients. Pain relief was successfully achieved in both groups (p<0.001), but the patients satisfaction was greater in the non-diabetic patients (p=0.0067). Revision surgery was more frequently performed in the DG than the CG (non-significant difference), and the time interval for such a second intervention was shorter (p=0.04) in the DG. A higher rate of post-operative complications was observed in the DG (p<0.0001). It is concluded that surgical treatment of elderly diabetic patients suffering from spinal stenosis improves BADL and ameliorates pain, but the results remain worse than those observed in non-diabetics. The outcome of diabetic patients depends upon the presence of other comorbidities, concurrent diabetic neuropathy, duration of diabetes and insulin treatment. Successful postoperative pain reduction remained the strongest factor associated with patients satisfaction.     

Reinnervation of the neurogenic bladder in the late period of the spinal cord trauma

STUDY DESIGN: Intercostal nerve to spinal nerve root anastomosis in chronic spine-injured patients. OBJECTIVES: To analyze the effectiveness of neurogenic bladder reinnervation in spinal cord-injured patients through artificial creation of sprouting (intercostal nerve to spinal nerve root anastomosis). SETTING: Center of Neurosurgery, Moscow, Russia. Operations were performed by Professor A Livshits. (At present, Professor A Livshits is working at the Spinal Care Unit, Meir General Hospital, Kfar Saba, Israel.) METHODS: A total of 11 patients with spinal cord injury of the L1 level were operated on in the late (chronic) stage. The neurological status and urodynamics were investigated before and 12 months after operation. A laminectomy from T11 to L3 was performed. Next, a neurolysis of the 11th and 12th intercostal nerves was carried out, at a distance of 20-21 cm, and transferred to the vertebral canal. The S2-S3 roots were then cut in their proximal portion and anastomosed end-to-end to the intercostal nerves. The results of urodynamic studies were calculated by the Wilcoxon signed rank test for comparison before and 12 months after operation. RESULTS OF URODYNAMIC STUDIES: Bladder capacity (ml) before operation - 489+/-79, after operation - 350+/-39, urine volume (ml) before - 18.2+/-17, after - 306.4+/-39.8, residual urine (ml) before - 459+/-99.4, after - 50+/-11.8. Detrusor tone (rel. units) before - 0.6+/-1.5, after 1.2+/-0.2; voiding pressure (cmH(2)O) before - 4.4+/-5.2, after - 30.5+/-4.9. Force of detrusor contraction before - 5+/-5.8, after - 32.8+/-5.5. Sphincter resistance (cmH(2)O) before - 6.5+/-3.8, after - 21.1+/-4.2. Significant improvements in bladder function were observed during the 10th to 12th postoperative months. Restoration of reflex voiding occurred in all patients; in eight of the 11 paresthesic in the groin and scrotum and reappearance of the bulbocavernous, anal and cremasteric reflexes were noted. CONCLUSION: These results suggest that a restitutive process occurs in the bladder under novel conditions of its nerve supply provided by the intercostal nerve and by new connections established between it and the bladder nerves. Spinal cord lesions that might benefit from nerve crossover surgery would be located at the conus, so functional intercostal nerves could be connected to sacral roots to bypass the injury in an attempt to restore central connections to the bladder.     

Observations on the safety and efficacy of surgical decompression for lumbar spinal stenosis in geriatric patients

This retrospective study examines the results of surgical decompression of the lumbar spinal canal in 122 geriatric patients (age range 75-89 years) treated under general anesthesia by the same surgeon between the years 1990 and 1999. Patient demographics, perioperative complications, pain profiles before surgery and at the time of data collection (December 2000), as well as overall mortality were recorded. One hundred and twenty-two patients were studied. The average age at the time of surgery was 78.8 years (range 75-89 years). No perioperative deaths were recorded. The mean time elapsed from surgery until patient follow-up was 45.7 months (range 12-119 months). Fourteen patients had died at the time of patient follow-up (December 2000). When compared to pain experienced before surgery, at the time of the interview a significant (P<0.0001) improvement in low-back and radicular pain as well as in the ability to perform daily activities (dressing, washing, getting out of bed and walking) was described. We conclude that, for geriatric patients rated as physical status I-II (>75 years) under the American Society of Anesthesiologists (ASA) classification, surgical release of lumbar spinal stenosis is a safe and effective treatment option. However, the suitability of ASA III patients requires further investigation.     

Urethral and bladder current perception thresholds: normative data in women

PURPOSE: Given increased evidence of sensory dysfunction in lower urinary tract pathology, we determined normative current perception threshold values in the lower urinary tract of asymptomatic women. MATERIALS AND METHODS: After receiving institutional review board approval women without lower urinary tract symptoms underwent current perception threshold testing of the urethra and bladder using a Neurometer constant current stimulator. Current perception threshold values were determined at 3 frequencies, including 2,000 Hz (corresponding to A-beta fibers), 250 Hz (corresponding to A-delta fibers) and 5 Hz (corresponding to C fibers). RESULTS: A total of 48 women with a mean age of 38 years (range 23 to 67) underwent current perception threshold testing. Normative values were established for the urethra and bladder at 2,000, 250 and 5 Hz. Median urethral current perception thresholds at 2,000, 250 and 5 Hz were 1.2 (IQR 0.76-1.5), 0.45 (IQR 0.33-0.56) and 0.11 mA (IQR 0.07-0.24), respectively. Median bladder current perception thresholds at 2,000, 250 and 5 Hz were 4.1 (IQR 2.0-6.3), 2.3 (IQR 0.87-5.5) and 1.4 mA (IQR 0.22-2.9), respectively. Urethral and bladder current perception thresholds increased significantly with subject age at all 3 frequencies (p<0.0005). Prior pelvic surgery was associated with an increased bladder current perception threshold at all 3 frequencies (p<0.005) but not with the urethral current perception threshold. CONCLUSIONS: We report urethral and bladder current perception thresholds for a large sample of asymptomatic women. These reference values may help elucidate changes in afferent nerve function in women with lower urinary tract dysfunction.     

Treatment of postdiscectomy low back pain by percutaneous posterior lumbar interbody fusion versus open posterior lumbar fusion with pedicle screws

BACKGROUND CONTEXT: Up to a fifth of the patients who had discectomy undergo spinal fusion because of disabling low back pain. PURPOSE: To compare the clinical outcome of percutaneous posterior lumbar interbody fusion (PPLIF) to that of open posterior lumbar fusion (PLF). STUDY DESIGN/SETTING: Two surgical methods that were tried in sequence at a university affiliated hospital. PATIENT SAMPLE: Sixty patients with disabling postdiscectomy low back pain. OUTCOME MEASURES: Pain intensity was scored on a visual analog scale (VAS) and the degree of disability was scored by the Oswestry disability index (ODI). METHODS: Thirty patients were treated by PPLIF. The outcome, after 24 months or more, was compared retrospectively with that of 30 consecutive suitable subjects who had been treated by PLF with pedicle screw fixation by the same surgeons for the same indication. RESULTS: In the PPLIF group, as compared with PLF group, mean operating time was shorter, blood loss was negligible, and mean hospital time was halved. By the last follow-up visit (greater than or equal to 2 years), pain and disability in PLF group had diminished by 31.9% and 20.1%, respectively. The corresponding figures in PPLIF group were 55.4% and 42.7%, respectively. CONCLUSIONS: In the context of postdiscectomy low back pain, PPLIF has proven, thus far, to be a safe procedure with improved clinical results.