Mateo Ziu, Bradley Dengler, Davin Cordell and Viktor Bartanusz
Primary spine infection secondary to intravenous drug abuse (IVDA) is a difficult clinical entity encountered by spine surgeons and infectious disease specialists. Patients tend to be noncompliant with the treatment and follow-up, and some continue to use IV recreational drugs even after the diagnosis of spine infection. The authors undertook this study to analyze the presentation, etiology, demographic characteristics, treatment, and outcome of primary pyogenic spinal infection in patients with IVDA as the major risk factor.
The medical records, radiology imaging, and laboratory results (white blood cell count, inflammatory markers, bacteriology cultures) of all patients with pyogenic spine infection and history of IVDA presenting to a tertiary care center from August 2005 through December 2013 were retrospectively reviewed. The department of neurosurgery database and the hospital electronic medical records of University Hospital in San Antonio were used to identify the cohort for our study.
A total of 164 patients with spinal infection were evaluated during the study period; 102 of these patients had a history of IVDA. Their average age was 45.4 years, and only 14 (13.7%) were women. The mean laboratory values at presentation included a white blood cell count of 11.1 × 103 cells/μl (range 0.5–32 × 103 cells/μl), erythrocyte sedimentation rate (ESR) of 74 mm/hr (range 9.9–140 mm/hr), and C-reactive protein (CRP) level of 67 mg/L (range 0.1–327 mg/L). Twenty-six patients (25.4%) had an associated epidural abscess. The most common organism isolated from cultures of the bone and/or blood was methicillin-sensitive Staphylococcus aureus (MSSA), which was found in 37 cases. A close second was methicillin-resistant S. aureus (MRSA), found in 23 cases. The most commonly involved region was the lumbar spine (24 cases [57.8%]), and most patients (69.6%) had involvement of only a single level. Eighty patients were initially treated with long-term IV antibiotic therapy, and only 22 underwent surgical intervention (24 procedures). Of the latter group, 8 patients underwent laminectomy alone while 16 required some type of instrumented stabilization. Of the patients requiring stabilization procedures, 2 (12.5%) required reoperation with extension of their surgical constructs to other levels. The average follow-up was 29.7 weeks (range 6 weeks to 3 years).
Diagnosis and management of spinal infection in patients with a history of IVDA is challenging. The data from this study show that initial laboratory values are difficult to interpret given that only a minority of these patients present with leukocytosis. Back pain was the only reliable predictor of spine infection. The authors' experience indicates that the majority of patients with spine infection and a history of IVDA can be successfully treated with IV antibiotic therapy alone.
Viktor Bartanusz, Mateo Ziu, David F. Jimenez and James M. Henry
Calcifying pseudoneoplasm of the spine is a rare nonneoplastic lesion of unknown origin described in adolescents and adults. Its clinical manifestations include axial pain, myelopathy, or radiculopathy. Surgery is the preferred method of treatment. The authors report the occurrence of calcifying pseudoneoplasm at the C1–2 cervical segment in a 22-month-old child who became completely asymptomatic 2 months after open biopsy. A review of the literature is presented, emphasizing the uniqueness of the presented case in comparison with the previously published cases. The 22-month-old healthy girl presented with sudden onset of neck pain. Due to persistence of the symptoms 2 weeks after onset, imaging studies were performed that revealed an inhomogeneous calcified mass extending from the transverse ligament to the C1–2 interlaminar space and facet joint on the left side. Open biopsy of the mass at the C1–2 lamina was performed. The histological features were consistent with calcifying pseudoneoplasm. The child's neck pain progressively improved and she remained asymptomatic at the 1-year follow-up. The postoperative MRI at 8 months did not reveal any progression of the lesion. Contrary to reported cases, calcifying pseudoneoplasm of the spine may occur as early as 2 years of age and should be included in the differential diagnosis of calcified lesions in this age group. Complete resection is not a prerequisite to clinical improvement when there is no compromise of neural structures; conservative management is appropriate.