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Pyogenic spondylodiscitis is uncommon and usually presents in the setting of immunosuppression. Streptococcus anginosus group are opportunistic pathogens that rarely cause this infection. We present a case of an immunocompetent 45-year-old male with extreme lower back pain, not even relieved by opioids. A magnetic resonance imaging done the day before arrival showed multiple lumbar disk degeneration and lumbar spondylosis. Initial examinations did not show significant alteration. During inpatient admission, his values of erythrocyte sedimentation rate and C-reactive protein increased, and a new magnetic resonance imaging with contrast revealed signs of spondylodiscitis at the L2-L3 level. He underwent open surgery for tissue sampling and stabilization of the affected segment. Blood culture, disk sampling culture, and myeloculture were positive for S. anginosus. Additional examinations were negative for immunosuppression or any underlying condition, and the dental evaluation only showed mild gingivitis. The patient received intravenous antibiotics, and the pain significantly improved after surgery. He was finally discharged and completed 8 weeks of antibiotics. The erythrocyte sedimentation rate and C-reactive protein values were normal 6 weeks after surgery, and on a 1-year follow-up, the magnetic resonance imaging showed stable post-surgical changes with no signs of infection.

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Abstract Objective To study the results of only posterior decompression and instrumentation in dorsal and dorsolumbar spine tuberculosis. Methods The patients (n = 30) who were included in this study had dorsal or dorsolumbar spine tuberculosis, with or without neurological deficit, and with or without deformity. All 30 patients were managed by only posterior approach decompression and instrumentation. We studied cases for correction and maintenance of deformity at dorsal and dorsolumbar spine, functional outcome by the Oswestry disability index (ODI) and visual analogue scale (VAS) scores, as well as neurological outcome by the Frankel grade. Results In the current series, 30 patients were operated with single stage posterior decompression and instrumentation, and showed significant improvement in neurological status and functional outcomes, which were accessed by the ODI score, VAS score, and Frankel grade. Conclusion The posterior (extracavitary) approach provides optimum access to the lateral and anterior aspects of the spinal cord for good decompression. It facilitates early mobilization and avoids problems of prolonged recumbency, provides better functional outcome, and significantly better sagittal plane kyphosis correction.

Resumo Objetivo Estudar os desfechos da descompressão posterior isolada e instrumentação na tuberculose da coluna dorsal e dorsolombar. Métodos Os pacientes (n = 30) incluídos neste estudo apresentavam tuberculose na coluna dorsal ou dorsolombar, acompanhada ou não por déficit neurológico e/ou deformidade. Todos os 30 pacientes foram tratados apenas por descompressão posterior e instrumentação. Estudamos a correção e manutenção da deformidade na coluna dorsal e dorsolombar, o desfecho funcional segundo o índice de deficiência de Oswestry (ODI) e a escala visual analógica (EVA); o desfecho neurológico foi estudado de acordo com a classificação de Frankel. Resultados Na atual série, 30 pacientes foram submetidos à descompressão posterior e instrumentação em estágio único e apresentaram melhora significativa no estado neurológico e desfecho funcional segundo os scores de ODI, EVA e classificação de Frankel. Conclusão A abordagem posterior (extracavitária) permite o acesso ideal aos aspectos laterais e anteriores da medula espinhal para uma boa descompressão. Facilita a mobilização precoce, evita problemas associados ao decúbito prolongado, proporciona melhor desfecho funcional e corrige a cifose no plano sagital de maneira significativamente melhor.

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Objective To describe the clinico-epidemiological, laboratory, and radiological characteristics of tuberculous spondylodiscitis in the Brazilian population, and to assess whether there are differences between patients in whom the etiological agent in Pott disease was isolated or not. Methods Patients diagnosed with tuberculosis (TB) of the spine (Pott disease) underwent follow-up between 2009 and 2019 at a quaternary hospital and were divided into 2 groups: successful isolation (SI) of the etiological agent (through bacilloscopy, culture, or positive molecular rapid test) and unsuccessful isolation (UI) of the etiological agent. Results From a total of 26 patients diagnosed with TB of the spine, 21 (80.7%) were male, with a mean age of 40 ± 22.5 years. The average lymphocyte counts were higher in the UI group (25.35 ± 13.08; p = 0.025) compared to the SI group (14.18 ± 7.48). Moreover, the monocyte/lymphocyte ratio was lower in the UI group (0.39 ± 0.22; p = 0.009) than in the SI group (0.89 ± 0.65). Relative lymphocyte counts higher than or equal to 16.7 had a sensitivity of 76.9% and specificity of 62.5% in the UI group. Values higher than or equal to 0.58 for the monocyte/lymphocyte ratio showed a sensitivity of 84.6% and specificity of 75.0% in the UI group. Conclusion No differences were observed regarding the clinico-epidemiological and radiological characteristics of the two experimental groups. However, the UI group had higher lymphocyte counts and a lower monocyte/lymphocyte ratio.

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Abstract Objective To describe the clinico-epidemiological, laboratory, and radiological characteristics of tuberculous spondylodiscitis in the Brazilian population, and to assess whether there are differences between patients in whom the etiological agent in Pott disease was isolated or not. Methods Patients diagnosed with tuberculosis (TB) of the spine (Pott disease) underwent follow-up between 2009 and 2019 at a quaternary hospital and were divided into 2 groups: successful isolation (SI) of the etiological agent (through bacilloscopy, culture, or positive molecular rapid test) and unsuccessful isolation (UI) of the etiological agent. Results From a total of 26 patients diagnosed with TB of the spine, 21 (80.7%) were male, with a mean age of 40 ± 22.5 years. The average lymphocyte counts were higher in the UI group (25.35 ± 13.08; p= 0.025) compared to the SI group (14.18 ± 7.48). Moreover, the monocyte/lymphocyte ratio was lower in the UI group (0.39 ± 0.22; p= 0.009) than in the SI group (0.89 ± 0.65). Relative lymphocyte counts higher than or equal to 16.7 had a sensitivity of 76.9% and specificity of 62.5% in the UI group. Values higher than or equal to 0.58 for the monocyte/lymphocyte ratio showed a sensitivity of 84.6% and specificity of 75.0% in the UI group. Conclusion No differences were observed regarding the clinico-epidemiological and radiological characteristics of the two experimental groups. However, the UI group had higher lymphocyte counts and a lower monocyte/lymphocyte ratio.

Resumo Objetivo Descrever as características clínico-epidemiológicas, laboratoriais e radiológicas da espondilodiscite tuberculosa na população brasileira e avaliar se há diferenças entre pacientes em que o agente etiológico da doença de Pott foi isolado ou não. Métodos Os pacientes diagnosticados com tuberculose (TB) da coluna (doença de Pott) foram acompanhados em um hospital quaternário entre 2009 e 2019 e divididos em 2 grupos: isolamento positivo (IP) do agente etiológico (por baciloscopia, cultura ou teste rápido molecular positivo) e isolamento negativo (IN) do agente etiológico. Resultados De um total de 26 pacientes com diagnóstico de TB da coluna, 21 (80,7%) eram do sexo masculino, e a média de idade era de 40 ± 22,5 anos. As contagens médias de linfócitos foram maiores no grupo IN (25,35 ± 13,08; p= 0,025) do que no grupo IP (14,18 ± 7,48). Além disso, a relação monócito/linfócito foi menor no grupo IN (0,39 ± 0,22; p= 0,009) do que no grupo IP (0,89 ± 0,65). O número relativo de linfócitos maior ou igual a 16,7 teve sensibilidade de 76,9% e especificidade de 62,5% no grupo IN. A razão monócito/linfócito maior ou igual a 0,58 teve sensibilidade de 84,6% e especificidade de 75,0% no grupo IN. Conclusão Não observamos diferenças em relação às características clínico-epidemiológicas e radiológicas entre os dois grupos experimentais. No entanto, o grupo IN apresentou maior número de linfócitos e menor razão monócito/linfócito.

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Patient with spondylodiscitis who presented kyphosis deformity with neurological compromise at the upper thoracic level, who was treated with a new right infraclavicular anterior thoracic approach, as a new alternative surgical technique. 72-year-old male with kyphosis deformity secondary to T2-T3 ASIA "C" spondylodiscitis, treated with C5 to T6 posterior cervicothoracic instrumentation and right infraclavicular transthoracic anterior approach utilizing an expandable cylinder. Within the literature review carried out in the search engines, no similar techniques to the one described in this article were found. Given the complexity of the surgical approach, this new technique is described as a new way for accessing the upper thoracic spine, demonstrating that the right infraclavicular anterior thoracic approach is a new alternative to access the upper thoracic spine from T1 to T4.

Paciente con espondilodiscitis que presentó deformidad cifótica con compromiso neurológico a nivel torácico superior, quien fue tratado con un nuevo abordaje torácico anterior infraclavicular derecho, como nueva técnica quirúrgica alternativa. Varón de 72 años con deformidad en cifosis secundaria a espondilodiscitis T2-T3 ASIA "C", tratado con instrumentación cervicotorácica posterior C5 a T6 y abordaje anterior transtorácico infraclavicular derecho con colocación de cilindro expandible. Dentro de la revisión bibliográfica realizada en los buscadores no se encontraron técnicas similares a la descrita en este artículo. Dada la complejidad del abordaje quirúrgico, esta nueva técnica se describe como una nueva forma de acceder a la columna torácica superior, demostrando que el abordaje torácico anterior infraclavicular derecho es una nueva alternativa para acceder a la columna torácica superior desde T1 a T4.

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BACKGROUND: Pyogenic spinal infections (PSIs) are a group of uncommon but serious infectious diseases that are characterized by inflammation of the endplate-disc unit. PSIs are considered more prevalent and aggressive among patients with chronic immunocompromised states. Association between PSIs and liver disease has not been systematically analyzed. The authors performed a systematic review to study baseline characteristics, clinical presentation, and mortality of patients with PSI in the setting of chronic liver disease. OBSERVATIONS: The authors presented the case of a 72-year-old female patient with chronic liver disease who presented with severe low back pain and bilateral lower weakness. Imaging studies showed T10-11 spondylodiscitis. The patient received decompression and fusion surgery with partial neurological improvement. The authors performed a systematic literature search of spondylodiscitis and liver disease, and eight published articles met the studies inclusion and exclusion criteria. These studies featured a total of 144 patients, of whom 129 met inclusion criteria (mean age, 60.5 years, range 40 to 83 years; 62% males). Lumbar infection was the most common report (67%), with Staphylococcus aureus (48%) as the main causative microorganism. Neurological compromise was present in 69% of patients. Surgical intervention occurred in 70.5% of patients, and the average duration of antibiotic treatment was 69.4 days. Postoperative complication rate was 28.5%, with a 30- and 90-day mortality of 17.2% and 24.8%, respectively. LESSONS: Pyogenic spondylodiscitis in patients with liver disease was associated with a high rate of neurological compromise, postoperative complications, and mortality.

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INTRODUCCIÓN Haemophilus parainfluenzae (HP) es un cocobacilo gram negativo y un patógeno oportunista. Rara vez se asocia a infecciones vertebrales o musculoesqueléticas, y está muy poco reportado en la literatura. PRESENTACIÓN DELO CASO Una mujer de 45 años, sana, que presentaba un historial de dos semanas de lumbalgia progresiva, fiebre, coriza y congestión nasal, y que tenía discitis intervertebral causada por HP, confirmada por dos hemocultivos positivos y hallazgos progresivos de resonancia magnética (RM) de columna lumbar. Los hallazgos de la RM fueron atípicos, y consistían en un absceso del psoas y pequeñas colecciones de líquido epidural e intraespinal anterior asociadas con espondilodiscitis. El diagnóstico inicial se retrasó debido a que la RM inicial no reveló hallazgos que sugirieran un proceso infeccioso. El tratamiento consistió en un ciclo prolongado de administración intravenosa seguida de antibióticos orales, lo que finalmente produjo una buena respuesta clínica. DISCUSIÓN Y CONCLUSIÓN El HP es un patógeno muy raro en la espondilodiscitis. No obstante, debe tenerse en cuenta, especialmente en pacientes que presentan lumbalgia y fiebre y/o bacteriemia por microorganismos gram negativos. El estudio inicial debe incluir una RM de la columna con contraste. Aunque es poco común, la espondilodiscitis y un absceso del psoas pueden presentarse concomitantemente. Los antibióticos prolongados son el pilar del tratamiento.

INTRODUCTION Haemophilus parainfluenzae (HP) is a gram-negative coccobacillus and an opportunistic pathogen. It is rarely associated with spinal- and musculoskeletal-site infections, and very little reported in the literature. CASE PRESENTATION An otherwise healthy, 45-year-old woman who presented with a two-week history of progressive low back pain, fever, coryza and nasal congestion, was found to have intervertebral discitis caused by HP, confirmed by two positive blood cultures and progressive lumbar spine magnetic resonance imaging (MRI) findings. The MRI findings were atypical, consisting of a psoas abscess and small anterior epidural and intraspinal fluid collections associated with spondylodiscitis. The initial diagnosis was delayed because the initial MRI failed to reveal findings suggestive of an infectious process. The treatment consisted of a long course of intravenous followed by oral antibiotics, ultimately yielding a good clinical response. DISCUSSION AND CONCLUSION Haemophilus parainfluenzae is a very rare pathogen in spondylodiscitis. Nonetheless, it should be considered, especially in patients presenting with low back pain and fever and/or gram negative bacteremia. The initial work-up should include contrast-enhanced MRI of the spine. Although rare, spondylodiscitis and a psoas abscess can present concomitantly. Prolonged antibiotics are the mainstay of treatment.

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RESUMEN La enfermedad de Pott o espondilodiscitis tuberculosa representa menos del 1% de los casos de tuberculosis. Sin embargo, el curso clínico indolente de esta enfermedad hace que su diagnóstico sea generalmente tardío, causando con ello la destrucción de las estructuras vertebrales. La deformidad resultante de la columna vertebral requiere tratamiento quirúrgico, el cual es complejo y requiere una estancia hospitalaria prolongada. Se describe el caso de un paciente varón de 52 años que fue diagnosticado de espondilodiscitis lumbar luego de la correspondiente evaluación clínica y estudios imagenológicos sin mostrar respuesta al tratamiento antibiótico empírico. Un abordaje transforaminal percutáneo, técnica mínimamente invasiva, permitió el diagnóstico de espondilodiscitis tuberculosa y la mejoría sintomática del paciente.

SUMMARY Pott's disease or tuberculous spondylodiscitis accounts for less than 1% of tuberculosis cases. However, the indolent clinical course of this condition leads to a generally delayed diagnosis and to the destruction of the vertebral structures. The resulting spinal deformity requires surgical treatment, which is complex and demands a prolonged hospital stay. In this report, we present the case of a 52-year-old male patient who was diagnosed with lumbar spondylodiscitis by clinical and imaging studies, without response to an empiric antibiotic treatment. Transforaminal percutaneous approach, a minimally invasive technique, allowed the diagnosis of tuberculous spondylodiscitis and a symptomatic improvement of the patient.

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Background: We analyzed the role of hypoalbuminemia, dialysis, and other risk factors that increase morbidity/ mortality following surgery for primary pyogenic spinal infections (PSIs). The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) that included 627 patients was utilized as our database. Methods: Primary spinal surgery for spondylodiscitis was evaluated in a ACS-NSQIP database involving 627 patients between 2010 and 2019. Outcome assessment included evaluation of 30-day postoperative morbidity, and mortality rates. Results: Within 30 postoperative days, complications occurred in 14.6% (92/627) of patients; 59 (9.4%) required readmission, and 39 (6.2%) required additional surgery. The most common complications were: wound infections, pneumonia, septic shock, and death (1.8%). Hypoalbuminemia (i.e., significantly associated with unplanned readmission and reoperation), and dialysis were the two major risk factors contributing to increased perioperative morbidity and mortality. Conclusion: Among 627 ACS-NSQIP patients undergoing primary surgery for PSIs, hypoalbuminemia and dialysis were associated with higher risks of major perioperative morbidity (i.e., within 30 postoperative days - mostly readmissions and reoperations) and mortality.

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PURPOSE: To identify the diagnostic yield and predictive factors for microbiological diagnosis in patients with spondylodiscitis through computed tomography (CT)-guided biopsy or aspiration. MATERIALS AND METHODS: A retrospective review of 102 patients with suspected spondylodiscitis who underwent CT-guided procedures in an 8-year period was conducted. Analyzed variables were demographic data, C-reactive protein, pre-biopsy MRI findings, prior antibiotic use, site of biopsy/aspiration, histopathological findings, culture results and radiation dose. RESULTS: The culture yield among all sites was 56%, 85.6% for paravertebral/discal fluid aspiration, 66.7% for disk-only biopsy, 52.9% for paravertebral soft tissue biopsy, and 39.6% for endplate bone-disk unit. Patients with paravertebral/disk collection on MRI had better yields when submitted to fluid aspiration instead of biopsy of other sites (78.9% vs. 36.6%; p = 0,006). Pyogenic etiology corresponded to 68.3% of cases and Staphylococcus aureus was the most common agent. Prior antibiotics exposure was associated with a lower yield (66.2% vs. 40.9%, p = 0,016). CONCLUSIONS: CT-guided procedures are safe and well-tolerated in patients with suspected spondylodiscitis, with good microbiologic yield particularly in the presence of paravertebral/discal abscess.

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Mucormycosis is a serious and rare fungal disease caused by opportunistic fungi of the zygomycete class, order Mucorales. The main clinical presentations are rhinocerebral, pulmonary, cutaneous, gastrointestinal, and disseminated infections. There are few reports in the literature of spondylodiscitis caused by mucormycosis. We report a 53-year-old male patient presenting with subcutaneous nodules and severe low back pain radiating to the lower limbs. The patient had systemic lupus erythematosus (SLE) for 8 years and corticoid-induced diabetes. He had been using 60 mg/day of prednisone in the last year, with a recent pulse therapy regimen with methylprednisolone and cyclophosphamide to control the renal dysfunction. Nuclear magnetic resonance (NMR) of the spine showed spondylodiscitis. The patient underwent spinal arthrodesis and lesion biopsy. The histopathological study of the vertebra reported a necro suppurative inflammation with numerous fungal structures described as a wide range of hyaline hyphae. The histopathology of the cutaneous nodule exhibited an extensive suppurative lesion centered on the subcutaneous tissue, associated with a large amount of hyphae, similar to that found in the spinal lesion, suggestive of mucormycosis. The fungal culture showed the growth of Rhizopus spp. Treatment was performed with amphotericin B lipid complex 5 mg/kg/day for 60 days. After antifungal treatment, there was a progressive reduction in the number of subcutaneous nodules and total improvement of the patient's low back pain, with recovery of his gait. At the 18-month outpatient visit follow-up, the patient was stable and without recurrence. In our case, timely diagnosis enabled the removal of the osteoarticular focus and the targeted therapy resulted in a satisfactory clinical response, without sequelae or complications, despite the patient's underlying immunosuppressed status.

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PURPOSE: Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification. METHODS: Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (wκ) to establish the inter- and intra-observer agreement. RESULTS: The inter-observer agreement was substantial considering the main categories (wκ = 0.77; 0.71-0.82), but moderate considering the subtypes (wκ = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (wκ = 0.65; 0.59-0.71), and moderate considering the subtypes (wκ = 0.58; 0.54-0.63). CONCLUSION: The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate.

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Background: Spondylodiscitis is a potentially catastrophic complication in patients on hemodialysis. It is slow and insidious onset and nonspecific symptoms have contributed to the late detection of this infectious process. Here, we reviewed the clinical characteristics and outcomes for patients on hemodialysis who developed spondylodiscitis who were diagnosed with spondylodiscitis. Methods: From 2011 to 2021, 11 (0.4%) of 2557 patients on hemodialysis were diagnosed with spondylodiscitis based on clinical symptoms, patients averaged 56.9 years of age, seven were male, and they presented with fever in just two cases. The most frequent comorbidities included hypertension (ten patients) and diabetes mellitus (seven patients). Here, we reviewed the clinical, radiological (i.e., MR scans), laboratory markers, and treatment choices (i.e., nonsurgical vs. surgical) for these 11 hemodialysis patients. Results: Ten of the 11 patients underwent spinal surgery, and five were later readmitted for recurrent of infections. There was just one nonsurgical mortality. Conclusion: For patients on hemodialysis, the new-onset of spinal pain may signal the onset of spondylodiscitis which should be rapidly diagnosed with MR studies and managed in a timely fashion either with antibiotic therapy and/or with surgery/antibiotics.

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ABSTRACT Background: Pyogenic Spinal Epidural Abscess (PSEA) is difficult to diagnose and can have devastating consequences. Magnetic Resonance Imaging (MRI) has high sensitivity and specificity, which are further increased with the use of contrast. There are several classifications of vertebral infectious processes, with emphasis on spondylodiscitis. Objective: To analyze the morphological parameters and their reproducibility; and to analyze different resonance imaging sequences. Methods: Using an image database, a morphological classification of PSEA was planned, with five parameters: Region (R), indicating the upper and lower limits of the abscess; Location (U), indicating whether the abscess is anterior or posterior within the canal; Compromise (C), meningeal or content of the structures; Association (A), discitis, osteomyelitis or both; and Perivertebral (P), anterior, lateral or posterior extravertebral abscess. The first three parameters give an idea of the volume of the PSEA, while the last two give the related infectious foci. Thirty-five cases were analyzed using Kappa's coefficient. Results: The global intra- and interobserver reproducibility was Kappa 0.81. The results for each parameter were as follows: R=0.95, U=0.92, C=0.66, A=0.70 and P=0.80. The first three give a notion of volume and the last two relate to the presence of vertebral infectious foci outside the canal. T2 weighted MRI with contrast was found to be the most effective imaging sequence. Conclusion: The morphological classification is simple to use, with excellent reproducibility. The parameters with the highest reproducibility were region and location, with values >0.92. The addition of gadolinium contrast increased the sensitivity of the diagnosis; the use of sagittal and axial images in T2-MRI was the most sensitive imaging sequence. Evidence Level III; Original.

RESUMO Introdução: O abscesso peridural piogênico da coluna (PSEA) é de difícil diagnóstico e pode ter consequências devastadoras. A ressonância magnética (RM) tem alta sensibilidade e especificidade, que são aumentadas ainda mais com contraste. Existem várias classificações dos processos infecciosos vertebrais, com ênfase em espondilodiscite. Objetivo: Analisar os parâmetros morfológicos e sua reprodutibilidade; e analisar as diferentes sequências de imagens de ressonância. Métodos: A partir de um banco de imagens, foi planejada uma classificação morfológica do PSEA, com cinco parâmetros: Região (R) que indica os limites superior e inferior do abscesso; Localização (U), indicando se o abscesso é anterior ou posterior dentro do canal; Comprometimento (C), meníngeo ou de conteúdo das estruturas; Associação (A), discite, osteomielite ou ambas e Perivertebral (P), abscesso extravertebral anterior, lateral ou posterior. Os três primeiros parâmetros dão uma ideia do volume da PSEA, enquanto os dois últimos mostram os focos infecciosos relacionados. Trinta e cinco casos foram analisados usando o coeficiente de Kappa. Resultados: A reprodutibilidade global intra e interobservador foi Kappa 0,81. Os resultados para cada parâmetro foram os seguintes: R = 0,95, U = 0,92, C = 0,66, A = 0,70 e P = 0,80. Os três primeiros dão uma noção de volume e os dois últimos se relacionam com a presença de focos infecciosos vertebrais fora do canal. A RM ponderada em T2 com contraste foi considerada a sequência de imagens mais eficaz. Conclusões: A classificação morfológica é simples de usar e tem excelente reprodutibilidade. Os parâmetros com maior reprodutibilidade foram região e localização com valores > 0,92. A adição do contraste de gadolínio aumentou a sensibilidade do diagnóstico; o uso de imagens sagitais e axiais em RM T2 foi a sequência de imagens mais sensível. Nível de Evidência III; Original.

RESUMEN Introducción: El absceso epidural espinal piógeno (PSEA) es difícil de diagnosticar y puede tener consecuencias devastadoras. La resonancia magnética (RM) tiene una alta sensibilidad y especificidad, que aumentan aún más con el contraste. Existen varias clasificaciones de los procesos infecciosos vertebrales, con énfasis en la espondilodiscitis. Objetivo: Analizar los parámetros morfológicos y su reproducibilidad; y analizar las diferentes secuencias de imágenes de resonancia. Métodos: Utilizando un banco de imágenes, se planificó una clasificación morfológica del PSEA, con 5 parámetros: Región (R), que indica los límites superior e inferior del absceso; Ubicación (U), que indica si el absceso es anterior o posterior dentro del canal; Compromiso (C), meníngeo o contenido de las estructuras; Asociación (A), discitis, osteomielitis o ambas; y absceso perivertebral (P), anterior, lateral o posterior extravertebral. Los tres primeros parámetros dan una idea del volumen del PSEA y los dos últimos los focos infecciosos relacionados. Se analizaron 35 casos mediante el coeficiente Kappa. Resultados: La reproducibilidad general intra e interobservador fue Kappa 0,81. Los resultados de cada parámetro fueron los siguientes:: R=0,95, U=0,92, C=0,66, A=0,70 y P=0,80. Los tres primeros dan una noción de volumen y los dos últimos se relacionan con la presencia de focos infecciosos vertebrales fuera del canal. La resonancia magnética ponderada en T2 con contraste se consideró la secuencia de imágenes más eficaz. Conclusiones: La clasificación morfológica es sencilla de utilizar y tiene una excelente reproductividad. Los parámetros con mayor reproducibilidad fueron la región y ubicación con valores > 0,92. La adición de contraste de gadolinio aumentó la sensibilidad del diagnóstico; el uso de imágenes sagitales y axiales en RM T2 fue la secuencia de imágenes más sensible. Nivel de Evidencia III; Original.

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Introdução e objetivo: a espondilodiscite é a infeção que atinge o disco intervertebral e as vértebras contíguas e representa dois a quatro % do total das infeções osteoarticulares em idade pediátrica. O agente patogénico é identificado em cerca de metade dos casos, sendo o Staphylococcus aureus o mais frequentemente isolado. Estudos recentes demonstram que entre os seis meses e os quatro anos a Kingella kingae tem um papel etiológico importante. O objetivo da exposição deste caso clínico foi chamar atenção para esta patologia rara cujo diagnóstico é difícil e exige um elevado nível de suspeição. Descrição do caso: criança de 16 meses, sexo masculino, com antecedentes de obstipação, é trazida múltiplas vezes à Urgência Pediátrica por quadro com mais de um mês de evolução de irritabilidade persistente, dor abdominal e recusa da marcha de agravamento progressivo. Na segunda vinda à Urgência Pediátrica apresentava dorsolombalgia à palpação da coluna dorsolombar e diminuição da lordose lombar, o que motivou a realização de avaliação analítica, sumária de urina, ecografia renal e vesical e radiografia dorsolombar sem alterações. Na terceira vinda à Urgência Pediátrica foi decidido internamento e solicitada ressonância magnética nuclear dorsolombar e cintigrafia óssea que revelaram espondilodiscite em D7-D8. Parâmetros analíticos sem alterações valorizáveis, exceto discreta elevação da velocidade de sedimentação. Hemoculturas e restante estudo etiológico negativo. Iniciou terapêutica endovenosa com cefu-roxime e flucloxacilina, com melhoria progressiva das queixas álgicas. Aquando da alta, assintomático, mantendo flucloxacilina oral até completar seis semanas de tratamento. Reavaliado posteriormente, encontrando-se assintomático, com um exame físico, reavaliação analítica e radiografia dorsolombar sem alterações. Conclusões: a espondilodiscite é uma identidade de difícil diagnóstico, especialmente na criança, devido à sua raridade, clínica inespecífica, impossibilidade de as crianças verbalizarem os seus sintomas e aos sinais radiológicos tardios, requerendo um alto índice de suspeição. O intervalo médio de tempo entre o início dos sintomas e o diagnóstico é de três semanas a três meses. A ressonância magnética é o exame de escolha. As hemoculturas são, muitas vezes, negativas. O pilar do tratamento é a antibioterapia por várias semanas, mas a sua escolha e duração são controversas. O tratamento inadequado pode originar dor crônica, sequelas ortopédicas graves e complicações neurológicas devastadoras. Quando atempada e adequadamente tratada, a maioria dos casos apresenta uma evolução clínica benigna e autolimitada.

Introduction and objective: spondylodiscitis is an infection that affects the intervertebral disc and the contiguous vertebrae. It represents two to four % of all osteoarticular infections in pediatric age. The pathogen is identified in about half of the cases, with Staphylococcus aureus being the most frequently isolated. Recent studies show that between six months and four years, Kingella kingaehas an important etiological role. The purpose of the presentation of this clinical case was to draw attention to this rare pathology whose diagnosis is difficult and requires a high level of suspicion. Clinical case description: a sixteen-month-old male, with a history of constipation, is brought multiple times to the Pediatric Emergency Department for a clinical picture with more than a month of evolution of persistent irritability, abdominal pain and refusal to walk, with progressive worsening. On the second visit to the Pediatric Emergency Department, he presented dorsolombalgia on palpation of the dorsolumbar spine and decreased lumbar lordosis, which led to the performance of analytical evaluation, urinalysis, renal and bladder ultrasound and dorsolumbar radiography, all without changes. On the third visit to the Pediatric Emergency Department, hospitalization was decided and dorsolumbar nuclear magnetic resonance and bone scintigraphy were requested, revealing spondylodiscitis in D7-D8. Analytical parameters had no changes, except for a slight increase in erythrocyte sedimentation rate. Blood cultures and remaining etiological study negatives. Intravenous therapy with cefuroxime and flucloxacillin was started with progressive improvement of pain. Upon discharge he was asymptomatic and maintained oral flucloxacillin until a total of six weeks of treatment. He was subsequently reassessed and remained asymptomatic, with a physical examination, analytical evaluation and dorsolumbar radiography without changes. Conclusions: spondylodiscitis is an identity that is difficult to diagnose, especially in children, due to its rarity, unspecific clinic, inability for children to verbalize their symptoms and late radiologic signs, requiring a high index of suspicion. The average time between the onset of symptoms and the diagnosis is three weeks to three months. Magnetic resonance imaging is the exam of choice. Blood cultures are often negative. The mainstay of treatment is antibiotic therapy for several weeks, but its choice and duration are controversial. Inappropriate treatment can lead to chronic pain, severe orthopaedic sequelae and devastating neurological complications. When timely and properly treated, most cases have a benign and self-limited clinical course.

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Background Fungal spondylodiscitis is not common but should be suspected in some cases. Candida tropicalis infections are being more frequently diagnosed due to some factors related to the microorganism. Case Description A C. tropicalis spondylodiscitis is described in a 72-year-old man who was treated with a combination of echinocandin (micafungin) and surgery. Conclusion The presence of some risk factors should promptly raise the suspicion of fungal spondylodiscitis. Treatment should be instituted as early as possible for the best outcome for the patient.

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Spondylodiscitis is an uncommon but serious complication after spine surgeries, and its main etiologic agent is Staphylococcus aureus . Fungal infections are rare and mostly caused by Candida albicans . We report the clinical case of a 69-year-old male patient who underwent a L2-S1 arthrodesis for degenerative scoliosis correction. He presented an infection 2.5 months after the procedure, a spondylodiscitis at L5-S1 levels, caused by Candida parapsilosis . The treatment consisted of surgical material removal, tricortical iliac graft placement in an anterior approach (L5-S1), lumbopelvic fixation (from T10 to the pelvis) in a posterior approach, and drug treatment with anidulafungin and fluconazole. This last medication was administered for 12 months, with good clinical outcomes.

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Abstract Sacral colpopexy is one of the standard procedures to treat apical pelvic organ prolapse. In most cases, a synthetic mesh is used to facilitate the colposuspension. Spondylodiscitis is a rare but potentially serious complication that must be promptly diagnosed and treated, despite the lack of consensus in the management of this complication.We report one case of spondylodiscitis after a laparoscopic supracervical hysterectomy and sacral colpopexy treated conservatively. We also present a literature review regarding this rare complication. A conservative approach without mesh removal may be possible in selected patients (stable, with no vaginal lesions, mesh exposure or severe neurologic compromise). Hemocultures and culture of imageguided biopsies should be performed to direct antibiotic therapy. Conservative versus surgical treatment should be regularly weighted depending on clinical and analytical progression. A multidisciplinary team is of paramount importance in the follow-up of these patients.

Resumo A colpopexia sacral é um dos procedimentos padrão para tratar o prolapso de órgãos pélvicos apical. Na maioria dos casos, uma tela sintética é usada para facilitar a colposuspensão. A espondilodiscite é uma complicação rara, mas potencialmente grave, que deve ser prontamente diagnosticada e tratada, apesar da falta de consenso no manejo dessa complicação. Relatamos um caso de espondilodiscite após histerectomia supracervical laparoscópica e colpopexia sacral tratada conservadoramente. Também apresentamos uma revisão da literatura sobre essa complicação rara. Uma abordagem conservadora sem remoção da tela pode ser possível em pacientes selecionadas (estáveis, sem lesões vaginais, exposição da tela ou comprometimento neurológico grave). Hemoculturas e cultura de biópsias guiadas por imagem devemser realizadas para direcionar a antibioticoterapia. O tratamento conservador versus o cirúrgico deve ser avaliado regularmente, dependendo da progressão clínica e analítica. Uma equipe multidisciplinar é de suma importância no acompanhamento desses pacientes.

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PURPOSE: To compare the bone fusion of freeze-dried allograft alone versus freeze-dried allograft combined autograft in spinal instrumentation due to spondylodiscitis. METHODS: A randomized prospective trial of patients with spondylodiscitis treated with surgical debridement and spinal fixation with freeze-dried bone allograft and autograft (Group 1) or freeze-dried bone allograft alone (Group 2) was performed. Patient follow-up was assessed with a CT-scan for bone fusion; consecutive serum inflammatory marker detection (C-reactive protein, [CRP], and erythrocyte sedimentation rate, [ESR]) and clinical assessment (pain, functional disability, and spinal cord injury recovery) were other outcome parameters. The primary outcome was the grade of bone allograft integration with the scale of Tan (which ranges from 1 to 4, with lower scores indicating a better fusion rate) at 1 year after surgery. RESULTS: A total of 20 patients were evaluated, 13 (65%) men and 7 (35%) women with a mean age of 47.2 (±14.3) years. Homogeneous distribution of demographic data was observed. A similar satisfactory bone graft fusion grade was observed in both graft groups at 1 year after surgery (p = 1.0000). Serum inflammatory markers gradually decreased in both groups after surgical intervention (CRP, p < 0.001; ESR, p < 0.01). At one-year follow-up, gradual improvement of pain, functional disability, and neurological spinal injury recovery in both graft groups were achieved. CONCLUSION: Freeze-dried allograft alone could be a therapeutic option for spinal fixation surgery due to spondylodiscitis since it achieves a satisfactory graft fusion rate and clinical improvement. LEVEL OF EVIDENCE: Level 1. Treatment. REGISTER: NCT03265561.

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Abstract Spondylodiscitis is an uncommon but serious complication after spine surgeries, and its main etiologic agent is Staphylococcus aureus. Fungal infections are rare and mostly caused by Candida albicans. We report the clinical case of a 69-year-old male patient who underwent a L2-S1 arthrodesis for degenerative scoliosis correction. He presented an infection 2.5 months after the procedure, a spondylodiscitis at L5-S1 levels, caused by Candida parapsilosis. The treatment consisted of surgical material removal, tricortical iliac graft placement in an anterior approach (L5-S1), lumbopelvic fixation (from T10 to the pelvis) in a posterior approach, and drug treatment with anidulafungin and fluconazole. This last medication was administered for 12 months, with good clinical outcomes.

Resumo As espondilodiscites são complicações infrequentes, porém graves em pós-operatórios de cirurgias da coluna vertebral, tendo como principal agente etiológico o Staphylococcus aureus. As infecções fúngicas são raras, sendo a Candida albicans a principal representante desse grupo. Relatamos o caso clínico de um paciente do sexo masculino, 69 anos, operado com artrodese de L2 a S1 para correção de escoliose degenerativa. O paciente apresentou quadro clínico infeccioso 2 meses e meio após o procedimento, relacionado à espondilodiscite L5-S1, causada por Candida parapsilosis. O tratamento consistiu na remoção do material cirúrgico, colocação de enxerto tricortical de ilíaco pela via anterior (L5-S1) e fixação lombopélvica (de T10 à pelve) pela via posterior, além de iniciar o tratamento medicamentoso com anidulafungina e fluconazol, mantendo essa última medicação por 12 meses, com boa evolução clínica.

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