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Study Design: Longitudinal Cohort Study OBJECTIVE.: The aim of this study was to determine whether duration of postoperative opioids is associated with long-term outcomes, and if initial postoperative opioid dosage is associated with opioid cessation after spine surgery., Summary of Background Data: Preoperative opioid use is associated with poor outcomes, but little evidence exists regarding the implications of opioid dosage and duration after spine surgery., Methods: Data from our state's prescription drug database was linked to our prospective clinical spine registry to analyze opioid dispensing and outcomes in elective surgical spine patients between 2010 and 2017. Patients were stratified based on preoperative chronic opioid use and multivariable regression was used to assess associations between duration of postoperative opioids and outcomes at one year, including satisfaction, chronic opioid use, and meaningful improvements in pain, disability, and quality of life. In a secondary aim, a Cox proportional hazards model was used to determine whether initial postoperative opioid dosage was associated with time to opioid cessation., Results: Of 2172 patients included, 35% had preoperative chronic opioid use. In patients without preoperative chronic opioid use, a postoperative opioid duration of 31 to 60 days was associated with chronic opioid use at 1 year (adjusted odds ratio [aOR]: 4.1 [1.7-9.8]) and no meaningful improvement in extremity pain (aOR: 1.8 [1.3-2.6]) or axial pain (aOR: 1.6 [1.1-2.2]); cessation between 61 and 90 days was associated with no meaningful improvement in disability (aOR: 2 [1.3-3]) and dissatisfaction (aOR:1.8 [1-3.1]). In patients with preoperative chronic opioid use, postoperative opioids for ≥90 days was associated with dissatisfaction. Cox regression analyses showed lower initial postoperative opioid dosages were associated with faster opioid cessation in both groups., Conclusion: Our results suggest that a shorter duration of postoperative opioids may result in improved 1-year patient-reported outcomes, and that lower postoperative opioid dosages may lead to faster opioid cessation., Level of Evidence: 2.

Study Design: Prospective cohort study., Objective: To analyze the serum and drain concentrations of antibiotics administered by two different routes and compare the results., Summary of Background Data: Systemic antibiotics are expected to reach the surgical site and maintain adequate concentrations of the drug to prevent infection. However, it is unknown whether systemically administered antibiotics reach and maintain such adequate concentrations at the surgical wound or not., Methods: Forty patients undergoing elective spine surgery received intra-wound Vancomycin (1 GM) before the wound closure and single dose of intravenous Gentamycin (80MG) immediately after surgery. Blood and drain samples were collected postoperatively to estimate serum and drain concentrations of Gentamycin and Vancomycin. Drug Estimation Protocol: Drug concentrations were estimated by ADVIA Centaur CP immunoassay (direct chemiluminescence). Gentamycin and vancomycin in the test samples competes with their respective acridinium ester-labeled gentamicin and vancomycin derivatives for monoclonal mouse anti-gentamycin and anti-vancomycin antibodies which are covalently coupled to paramagnetic particles in the solid phase., Results: Gentamycin attained peak serum levels at 6 hours following administration with an average value of 9.90 ± 3.1 μg/mL which was decreased to 6.76 ± 2.6 μg/mL at 12 hours and steadily declining thereafter. Even though, the drug concentrations in the drain collection from the wound also attained peak levels at 6 hours, the drug concentrations were lower (3.75 ± 1.4 μg/mL) than that of serum concentrations and inadequately attained the recommended target peak of Gentamycin (4-12 μg/mL).Wound levels of local vancomycin were significantly higher at 6 hours (413.4 ± 217.3 μg/mL) and well maintained even at 72 hours. Serum vancomycin levels were observed to be highest at 6 hours in negligible concentrations of 6.06 ± 2.2 μg/mL., Conclusion: After prophylactic systemic administration of the antibiotics, the antibiotic drug concentrations in the wound are much lower than the serum concentrations at any given time. After local intra-wound application of antibiotics, the drug concentrations in the wound are well maintained even after 72 hours., Level of Evidence: 3.

Study Design: Systematic review and meta-analysis., Objective: Compare outcomes of adult patients undergoing spinal fusion surgery who receive and do not receive perioperative antifibrinolytics to reduce operative blood loss., Summary of Background Data: The clinical potential for antifibrinolytics such as tranexamic acid and epsilon aminocaproic acid to significantly reduce blood loss during adult spinal fusion surgery remains underexplored. Outcomes for assessment included operative blood loss, and other surgical, clinical, and haematological outcomes., Methods: We followed the recommended Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. Electronic database searches identified 2041 for screening. Data were extracted and analyzed using meta-analysis of proportions., Results: A total of 11 randomized controlled trials with a total of 937 adult spinal fusion surgery patients were included for analysis. There were 472 (50%) patients who were treated with antifibrinolytics, with 345 of 472 (73%) and 127 of 472 (27%) receiving tranexamic acid and epsilon aminocaproic acid respectively. The use of antifibrinolytics was associated with significantly lower intraoperative (MD -127.08 mL; P = 0.002) and total blood loss (MD -229.76 mL; P < 0.00001), as well as incidence of blood transfusion (OR 0.58; P = 0.04). There was no significant difference with antifibrinolytic use in terms of many surgical parameters, including surgery duration (P = 0.50), overall complications (P = 0.21), and length of stay (P = 0.88). Finally, postoperative haemoglobin was significantly greater (MD 0.30 g/dL; P = 0.02) following antifibrinolytic use, with other haematological parameters mostly unaffected., Conclusion: Based on the highest level comparative evidence available, the possibility for blood loss reduction in adult spinal fusion surgery with the use of perioperative antifibrinolytics is not unreasonable, as it appears both efficacious and safe. In addition to further, larger investigations to validate the associations found in this study, practical aspects such as cost-benefit analysis, and long-term follow-up will further enhance our understanding., Level of Evidence: 1.

Study Design: Level III, Retrospective observational study., Objective: To determine if there is an increased risk of developing cancer after exposure to high-dose recombinant human bone morphogenetic protein-2 (rhBMP-2) and if risk is dose and/or exposure-dependent., Summary of Background Data: Concerns have been raised regarding a relationship between rhBMP-2 and cancer., Methods: A total of 642 adult deformity patients from a single institution receiving a cumulative rhBMP-2 dose ≥40 mg from July, 2002 to July, 2009 were identified. Patients with a history of surveillance, epidemiology, and end result (SEER) cancer before rhBMP-2 exposure were excluded. To determine the occurrence of a cancer event, questionnaires were mailed and telephone follow up attempted for nonresponders. Only cancers tracked by the National Cancer Institute (NCI) SEER registry were included. Observed cancer counts were compared to expected cancer counts based on general population incidence rates within 5-year age strata. Cumulative incidence competing risk (CICR) modeling was used to evaluate the association between rhBMP-2 exposure and cancer controlling for potential confounding variables., Results: Forty-nine patients were lost-to-follow up, leaving 593 patients (92.4%; 138 males/455 females) available for analysis. Mean age was 52.8 years at the time of first exposure. Mean cumulative rhBMP-2 dose was 113.5 mg with 85% having one exposure (range: 1-8). Mean follow-up [date of exposure to date of death (regardless of cause) or returned completed questionnaire] was 5.6 ± 1.9 years; median follow up was 5.4 years. A total of 342 patients have greater than 5-year follow up. Minimum follow up was 2.0 years or until occurrence of a SEER cancer. Our total 8-year cumulative incidence of new SEER cancer accounting for the competing risk of death was 7.4% for 30 cancers in 593 patients. Fewer cancers were observed than expected based on general population rates, though the difference was not statistically significant (expected = 34; standardized incidence ratio = 0.88, 95% confidence interval, CI = 0.60-1.26). CICR found neither cumulative rhBMP-2 dose (hazard ratio, HR = 0.995, 95% CI 0.988-1.003; P = 0.249) nor number of exposures (HR = 0.776, 95% CI 0.359-1.677; P = 0.519) increased the risk of developing a postexposure cancer after controlling for known cancer risk factors., Conclusion: The incidence of a SEER cancer after rhBMP-2 exposure was similar to incidence reported by the NCI. There were no significant rhBMP-2 dose or multi-exposure related risks of developing a life-threatening cancer., Level of Evidence: 3.

Study Design: Retrospective cohort study., Objective: The aim of this study was to identify factors independently associated with antibiotic treatment failure in patients with spinal osteomyelitis., Summary of Background Data: There are few studies that have identified risk factors for antibiotic treatment failure in medically managed spinal osteomyelitis. Identifying such factors could help to identify patients who can be treated solely with antibiotics., Methods: All patients who underwent antibiotic treatment for spinal osteomyelitis in one of our institutions between January 1, 2001 and January 1, 2015 were identified. Patients who underwent surgery before the start of the antibiotic treatment were excluded., Results: We included 215 patients with a mean age of 58 years; 63 (29%) patients had failure of antibiotic treatment. Diabetes (hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.03-2.79, P = 0.037), fever (HR 1.61, 95% CI 0.93-2.79, P = 0.088), osteomyelitis at an additional site (HR 5.17, 95% CI 2.63-27.9, P = 0.001), and the presence of an epidural abscess (HR 1.91, 95% CI 1.05-3.45, P = 0.033) were associated with failure of antibiotic treatment. In the multivariate Cox regression analysis, diabetes (HR 1.69, 95% CI 1.03-2.79, P = 0.019), osteomyelitis at an additional site (HR 8.26, 95% CI 2.51-27.2, P = 0.001), fever (HR 1.77, 95% CI 1.00-3.12, P = 0.050), and the presence of an epidural abscess (HR 1.82, 95% CI 1.06-3.13, P = 0.030) were independently associated with failure of antibiotic treatment., Conclusion: Antibiotic treatment failed in 29% of patients; diabetes, current other osteomyelitis, and having an epidural abscess were independently associated with failure of antibiotic treatment., Level of Evidence: 3.

Study Design: A consecutive retrospective cohort study from 2008 to 2013 at a single tertiary-care institution was conducted., Objective: The aim of the study was to characterize recovery from pain and neurologic deficit after surgery for vertebral osteomyelitis (VO), and identify incidence of postoperative adverse events., Summary of Background Data: A minority of patients with VO require surgery. Although prior studies have characterized outcomes after medical management, the morbidity after surgery is poorly defined., Methods: The primary outcome was change from baseline in a Modified McCormick Scale (MMS, 1-5 scale), whereas secondary outcomes included reoperation and change in self-reported pain Visual Analog Scale (VAS, 0-10 scale). MMS and VAS were collected throughout the postoperative course as surrogates for neurologic function and degree of pain. Intraoperative, short-term postoperative (<30 d), and long-term neurologic complications were recorded. New-onset neurologic deficits in the postoperative period were considered neurologic complications., Results: Fifty patients were included; a majority (52%) presented with a neurologic deficit. The median length of follow-up was 18 months. A statistically significant improvement in MMS was observed by 12 months postoperatively, whereas an improvement in VAS was observed by 3 months. The mean improvement in MMS at last follow-up was 0.35, whereas the mean improvement in VAS was 3.40. One quarter of patients required reoperation. At 24 months postoperatively, 10% died, 26% underwent reoperation, 42% experienced a neurologic complication, and 60% experienced at least one of these 3 adverse events., Conclusion: This is the first study to investigate neurologic complications, reoperation, and pain in a longitudinal manner after surgery for VO. We observed statistically significant improvements in MMS and VAS in the postoperative period. Despite these improvements, the 24-month incidence of overall adverse events was 60%. Patients and clinicians should be aware of the clinical improvement but high incidence of adverse events after surgical management of VO., Level of Evidence: 4.

Study Design: Retrospective clinical study., Objective: The aim of this study is to reveal the effectiveness of HBO therapy in iatrogenic spinal infections intractable to antibiotic therapy alone., Summary of Background Data: The efficiency of hyperbaric oxygen (HBO) therapy, which is currently being used in many areas, has been proven in infections in deep and superficial locations and in osteomyelitis. The aim of this study is to reveal effectives of HBO therapy in iatrogenic spinal infections intractable to antibiotic alone therapy., Methods: HBO therapy was given to 19 cases of iatrogenic spinal infection between 2008 and 2013. Adjuvant HBO therapy was applied to cases that had exhibited no improvement in clinical and laboratory findings despite medical treatment for at least 3 weeks. Several parameters including demographic characteristics, surgical area, etiology and the surgical treatment modality, microbiology (culture material and causative organism), clinical and laboratory results, duration of HBO therapy, and outcome were reviewed., Results: The mean age was 54.6 years (range: 32-75 years). Iatrogenic spinal infections were most frequent in the lumbar region. It occurred after spine instrumentation in 12 cases and after micro-discectomy in 7 cases. The average number of HBO therapy sessions applied was 20.1 (range: 10-40). Wound discharge and clinical and laboratory findings recovered in all cases at the end of the therapy course. No revision or removal of the instrumentation was necessary in the instrumented cases., Conclusion: HBO therapy is a treatment modality, which is safe and efficient as an adjuvant therapy in the treatment of infections. It was also seen to be effective in the prevention of revision procedures and instrumentation failures in iatrogenic osteomyelitis cases, which had occurred following spinal instrumentation., Level of Evidence: 4.

Study Design: A case of recurrent giant cell reparative granuloma (GCRG) of the lumbar spine successfully treated with denosumab is reported; a fully human monoclonal antibody against the receptor activator of nuclear factor kappa B (RANK) ligand (RANKL)., Objective: To report the first case of recurrent GCRG of the lumbar spine treated with denosumab., Summary of Background Data: GCRG is a non-neoplastic osteofibrous lesion usually found in the maxilla and mandible but rarely in the spine. It is clinically distinct from giant cell tumor of bone (GCTB), although common histological characteristics such as the proliferation of spindle-shaped stromal cells and multinucleated giant cells are shared. Denosumab has recently been reported to be effective for unresectable GCTB; however, there is only one report of its effect on GCRG. Moreover, the effect of denosumab on GCRG of the spine is unknown., Methods: The clinical course, radiological features, pathology, and treatment outcome of a patient with recurrent GCRG of the lumbar spine treated with denosumab are documented., Results: Denosumab treatment was used for this patient with unresectable recurrent GCRG of the lumbar spine. Follow-up lumbar radiography showed significant bone formations in the tumor lesion after 3 months of treatment. On follow-up computerized tomography scans of the L2 and L3 vertebral lesions, the replacement of osoteolytic lesions by the formation of cortical-like bone tissue was clearly identified., Conclusion: We report the first case of recurrent GCRG of the spine successfully treated with denosumab. Treatment with denosumab induced significant bone formation in the unresectable lumbar lesion with stable clinical improvement during the 12-month follow-up period without apparent complications. Denosumab shows promise as a new alternative treatment option for osteoclastic giant cell-rich tumors, such as GCRG, especially for unresectable lesions of the spine., Level of Evidence: 4.

Study Design: Retrospective cohort study., Objective: To evaluate the ability of local vancomycin powder to prevent deep wound infection after thoracolumbar and lumbar spinal fusion for open deformity cases., Summary of Background Data: Recent studies report that local delivery of vancomycin powder is associated with a decrease in spinal surgical site infection (SSI). This study compares deformity fusion cases before and after the routine application of spinal vancomycin powder., Methods: Posterior spinal deformity surgical procedures by a single institution were reviewed from January 2011 to April 2013. Routine application of vancomycin powder started in April 2012. Inclusion criteria included adult patients who underwent posterior fusion for deformity pathologies, including spondylolisthesis, kyphosis, sagittal imbalance, and scoliosis. Each cohort's baseline characteristics including infection risk factors, operative data, and rates of wound infection were compared. Associations between infection and vancomycin powder, with and without propensity score adjustment for risk factors were determined using logistic regression., Results: A total of 306 patients were included in the study. All measured baseline and operative variables were statistically similar between untreated (n = 150) and those who received vancomycin powder (n = 156). No significant change in deep wound infection rate was seen between the control (5.3%) and intervention group (5.1%, P = 0.936). Logistic regression with and without propensity score adjusted for risk factors demonstrated that the use of vancomycin powder did not impact the development of SSI (odds ratio [95% confidence interval]: 1.01 [0.36-2.79], P = 0.9910) and (odds ratio [95% confidence interval]: 0.87 [0.31-2.42], P = 0.7876), respectively., Conclusion: The local application of powdered vancomycin was not associated with a significant difference in the rate of deep SSI after spinal deformity surgery, and other treatment modalities are necessary to limit infection for this high-risk group. This study is in contrary to prior studies, which have reported a decrease in SSI with vancomycin powder., Level of Evidence: 2.

Study Design: Case report., Objective: To report a rare case of calcifying pseudotumor of the thoracic spine that resolved completely with Indomethacin treatment., Summary of Background Data: A 48-year-old male patient presented with a complaint of left T9 radiculopathy. Computed tomography scan and magnetic resonance images showed a calcifying pseudotumor of the thoracic spine. The nature of this disease remains unknown. This lesion behaves as a tumor-like lesion that is probably inflammatory in nature with a bone-forming potential., Methods: The patient was treated conservatively with Indomethacin 25 mg 3 times daily for 8 weeks. The lesion was monitored with computed tomography and magnetic resonance imaging at 8 weeks and at 16 weeks after initiation of treatment., Results: The patient had radicular pain for 8 weeks and sleep disturbance for 6 weeks prior to treatment. After he started taking Indomethacin 25 mg 3 times daily, the radicular pain resolved on the third day of Indomethacin treatment. The size of the mass reduced significantly at eighth week follow-up and resolved completely at 16 weeks of follow-up., Conclusion: Calcifying pseudotumor of spine should be treated with a trial of Indomethacin before surgical option is offered, unless the patient has a significant progressive neurological deficit that requires urgent surgical intervention.

Study Design: A retrospective cohort analysis., Objective: To determine the effect of biological agents (BAs) on the development and progression of cervical spine lesions and identify predictors of lesion progression., Summary of Background Data: The introduction of BAs has facilitated advances in the treatment of rheumatoid arthritis (RA). BAs reduce disease activity and limit structural joint damage. However, the effect of BAs on cervical spine lesions remains unclear., Methods: Thirty-eight subjects who received more than 2 years of continuous BA treatment were enrolled. The mean x-ray interval was 4.4 years. RA activity was evaluated by disease activity score (DAS)-C reactive protein (CRP) and matrix metalloproteinase (MMP)-3. Radiographical definitions of cervical lesions were atlanto-dental interval (ADI) more than 3 mm for atlanto-axial subluxation (AAS), Ranawat value less than 13 mm for vertical subluxation (VS), and anterior or posterior listhesis more than 2 mm for subaxial subluxation (SS). Definitions of radiographical progression were an increase of ADI more than 2 mm for AAS, a decrease of both Ranawat and Redlund-Johnell values more than 2 mm for VS, and an increase of listhesis more than 2 mm for SS., Results: RA activity responded dramatically to BA therapy (DAS-CRP from 4.3 to 2.3, P < 0.01; MMP-3 from 207.9 ng/mL to 105.6 ng/mL, P < 0.01). Baseline radiographical evaluation showed no pre-existing cervical spine lesions in 12 cases, AAS in 15 cases, and VS in 11 cases. Radiological progression was found in 1 (8%) patient in the no lesion group, 12 patients (80%) in the AAS group, and 9 patients (80%) in the VS group. The incidence of progression was significantly lower in the no lesion group compared with the other groups. Multivariate regression analysis showed that the presence of pre-existing cervical lesions was the single greatest predictor of progression., Conclusion: BAs prevented the development of de novo cervical spine lesions in patients with RA, but failed to inhibit progression of pre-existing RA lesions.

Study Design: A case report., Objective: To describe a patient with a primary extensive spinal subarachnoid cysticercosis that was successfully treated with a combination of surgical removal and albendazole., Summary of Background Data: Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system. It is mostly intracranial, but primary cysticercosis, although rare, can occur in the spinal canal. Neurological morbidity can occur if NCC is not properly treated; therefore, NCC should be considered as a lesion of primary nerve compression, which occurs within spinal canal as well as cranial cavity., Methods: A 48-year-old male patient presented with an 18-month history of progressive lower limb weakness and urinary incontinence. Contrast-enhanced lumbar magnetic resonance image showed multiple intradural and extramedullary masses and cysts from T12 to S1. A cervicothoracic magnetic resonance image revealed whole cervical and upper thoracic involvement. The patient was treated with a combination of surgical removal and orally administered albendazole., Results: A histopathological examination confirmed cysticercosis. After the treatment, cysticercosis had disappeared on follow-up. The patient's motor weakness in the lower limbs and urinary function were improved., Conclusion: Spinal subarachnoid cysticercosis can occur via direct hematogenous dissemination from a gastrointestinal tract. The primary spinal cysticercosis can be dropped distantly in the spinal cavity by cerebrospinal fluid circulation like intracranial cysticercosis, and extensive spinal subarachnoid cysticercosis can be successfully treated with a combination of surgical removal and cysticidal drugs.

Study Design: Retrospective analysis of a population-based insurance claims data set., Objective: To determine the risk of repeat fusion and total costs associated with bone morphogenetic protein (BMP) use in single-level lumbar fusion for degenerative spinal disease., Summary of Background Data: The use of BMP has been proposed to reduce overall costs of spinal fusion through prevention of repeat fusion procedures. Although radiographic fusion rates associated with BMP use have been examined in clinical trials, few data exist regarding outcomes associated with BMP use in the general population., Methods: Using the MarketScan claims data set, 15,862 patients that underwent single-level lumbar fusion from 2003 to 2007 for degenerative disease were identified. Propensity scores were used to match 2372 patients who underwent fusion with BMP to patients who underwent fusion without BMP. Logistic regression models, Kaplan-Meier estimates, and Cox proportional hazards models were used to examine risk of repeat fusion, length of stay, and 30-day readmission by BMP use. Cost comparisons were evaluated with linear regression models using logarithmic transformed data., Results: At 1 year from surgery, BMP was associated with a 1.1% absolute decrease in the risk of repeat fusion (2.3% with BMP vs. 3.4% without BMP, P = 0.03) and an odds ratio for repeat fusion of 0.66 (95% confidence interval [CI] = 0.47-0.94) after multivariate adjustment. BMP was also associated with a decreased hazard ratio for long-term repeat fusion (adjusted hazards ratio = 0.74, 95% CI = 0.58-0.93). Cost analysis indicated that BMP was associated with initial increased costs for the surgical procedure (13.9% adjusted increase, 95% CI = 9.9%-17.9%) as well as total 1-year costs (10.1% adjusted increase, 95% CI = 6.2%-14.0%)., Conclusion: At 1 year, BMP use was associated with a decreased risk of repeat fusion but also increased health care costs.

Study Design: Comparative biomechanical study was conducted in osteoporotic human cadaveric spines., Objective: Determine the influence of the volume of polymethyl methacrylate injected through a fenestrated pedicle screw on the pullout strength and on the ability to safely remove the implant., Summary of Background Data: Pedicle screw fixation in the osteoporotic spine can be improved by the addition of bone cement. Various injection techniques have been used. While improvement has been shown for the pullout strength, the optimal volume of cement to inject has not been previously studied., Methods: Seven osteoporotic spines were instrumented with a standard and a fenestrated pedicle screw augmented with polymethyl methacrylate at each level (T7-L5). Three volumes of bone cement were randomly injected and stratified to the thoracic (0.5 cc, 1.0 cc, and 1.5 cc) and lumbar spine (1.5 cc, 2.0 cc, and 2.5 cc). Axial pullout strength and removal torque of the pedicle screws were quantified., Results: The pullout strength of the fenestrated screw was normalized with respect to its contralateral control. Student paired t tests were conducted and a statistically significant increase was noted for 1.0 cc (186 ± 45%) and 1.5 cc (158 ± 46%) in the thoracic spine and for 1.5 cc (264 ± 193%), 2.0 cc (221 ± 93%), and 2.5 cc (198 ± 42%) in the lumbar spine. There was no significant difference with higher volumes of cement. The median removal torque was 0.34 Nm for the standard and 1.83 Nm for the augmented screws. When the augmented implants were removed, the bone cement sheared completely off at the fenestrations in 15 of the 17 cases., Conclusion: Significant increases in pullout strength can be accomplished by injecting a limited quantity of bone cement through a fenestrated screw while minimizing the risks associated with higher volume. The majority of implants were removed without damaging the vertebra as the bone cement sheared off at the fenestrations.

Study Design: Report of 2 cases of sarcoidosis involving vertebrae successfully treated with tumor necrosis factor-α inhibitor (TNF-α antagonist)., Objective: To disseminate knowledge concerning successful treatment of sarcoidosis involving the axial skeleton with the use of TNF-α blockers., Summary of Background Data: Osseous sarcoidosis most commonly involves small bones of hands and feet; vertebral involvement is rare, and currently there is no consensus on optimal treatment., Methods: Two cases are described detailing patients with extrapulmonary sarcoidosis involving vertebral bodies, retractable to conventional treatment, who were treated with TNF-α antagonists., Results: We observed a remarkable response following the administration of TNF-α blockers in vertebral sarcoidosis with marked resolution of lytic lesions. The patients remained asymptomatic with no recurrence of their disease., Conclusion: Vertebral sarcoidosis is a rare manifestation of osseous sarcoidosis. Symptomatic patients are treated with various immunosuppressive therapies. We propose utilizing TNF-α blocking agents in patients who fail to respond to first-line therapy.

Study Design: A case report describing chronic recurrent multifocal osteomyelitis (CRMO) with initial presentation limited to spine, successfully treated by anti-TNF-alpha therapy after failure of conventional treatment methods., Objective: To describe an unusual manifestation and treatment of a rare disease., Summary of Background Data: CRMO is a rare inflammatory bone disease that should be differentiated from bacterial osteomyelitis. Rarely, it can affect the spine and in this case the most important differential diagnosis is infectious spondylodiscitis. The disease has an unpredictable course with exacerbations and spontaneous remissions. Although the majority of cases remit spontaneously (or after the use of nonsteroidal anti-inflammatory drugs [NSAIDs]), some progressive and resistant cases have been reported., Methods: We describe a case of CRMO with an unusual clinical presentation emphasizing the importance of this finding as a differential diagnosis of spondylodiscitis and comment on the available treatment alternatives., Results: A 17-year-old man presented with debilitating dorsal spine pain. Magnetic resonance imaging of the spine revealed bone lesions at multiple vertebral levels. After failure of antibiotic treatment, the diagnosis of CRMO was suggested. An initial good response to NSAIDs was followed by a recurrent course and involvement of peripheral joints besides the use of corticosteroids and other drugs. The introduction of infliximab was followed by complete remission of the disease., Conclusion: Our observation highlights the need of awareness for the differential diagnosis in suspected cases of osteomyelitis not responding to antibiotics. Anti-TNF-alpha agents should be considered in CRMO refractory cases.

Study Design: Prospective, observational in vivo study., Objective: The aim of this study was to determine the incidence of simultaneous epidural and vascular contrast injection during cervical transforaminal epidural injections., Summary of Background Data: In the lumbar spine, vascular contrast patterns are more than twice as likely to appear simultaneous to the anticipated epidural pattern, than they are to occur alone. This is important because practitioners are more likely to miss a vascular pattern when it appears simultaneous to the expected epidural flow. The incidence of intravascular penetration in cervical transforaminal epidural injections is known to exceed than that of lumbar injections, however, no study has determined the incidence of simultaneous epidural and vascular injection in the cervical spine., Methods: Contrast patterns were observed with live fluoroscopy during 121 injections performed on 82 patients and categorized as one of the following: epidural only, vascular only, or simultaneous epidural and vascular., Results: The incidence of simultaneous epidural and vascular injection during cervical transforaminal epidural injections was 18.9%. The incidence of vascular only injection was 13.9%, for a total vascular injection incidence of 32.8%. There was no correlation between the observed contrast pattern with patients' age, sex, side of injection, needle gauge, or diagnosis. There was a significant correlation between the level of injection and the risk of vascular injection. The higher the injection level, the higher the probability of a vascular injection. Fluoroscopy time was significantly increased when a vascular injection was identified., Conclusion: Simultaneous epidural and vascular injection accounts for over half of all vascular injections during cervical transforaminal epidural injections. With the risk of severe complications and high incidence of vascular injections in the cervical spine, live fluoroscopy is recommended during contrast injection with specific attention to simultaneous epidural and vascular flow.

Study Design: Prospective observational cohort., Objective: Correlate epidural inflammatory cytokines with the clinical response to epidural steroid injection in patients with lumbar nerve root irritation., Summary of Background Data: Some back pain syndromes are thought to be associated with activation of inflammatory pathways and others may be associated with primary mechanical derangements. Human studies providing detailed evidence for the primary inflammatory causation, which may be best treated with anti-inflammatory strategies, are lacking. There are currently no accurate diagnostic tests to predict the response to epidural steroid injection or surgical intervention in back pain and sciatica syndromes. METHODS.: Forty-seven consecutive patients with lumbar degenerative changes and low back and/or leg pain were prospectively enrolled. An epidural lavage was performed, followed by injection of marcaine/depo-medrol. Subjects scored their pain before and 3 months after the procedure. The immunoreactivity of an array of cytokines was measured in lavage samples and compared with clinical response to the therapeutic injection. Ten subjects underwent repeat epidural lavage sampling 3 months after the steroid injection., Results: Interferon gamma (IFNgamma) was the most consistently detected cytokine. IFNgamma-immunoreactivity also highly correlated with reported reduction of pain 3-months after the epidural steroid injection. In subjects reporting significant pain relief (>50%) from the injection, mean [IFNgamma] was significantly greater compared with patients experiencing no significant relief. The IFNgamma-immunoreactivity in repeat lavage samples decreased to trace residual concentrations in patients who reported pain relief from the steroid injection., Conclusion: The presence of epidural IFNgamma-immunoreactivity corresponding to >10 pg/mL predicted significant pain relief after epidural steroid injection with >95% accuracy. These results suggest that IFNgamma may be part of a biochemical cascade triggering pain in sciatica; IFNgamma-immunoreactivity may aid as a biomarker for predicting the response to steroid therapy and/or surgical intervention, and may serve as a future therapeutic target.

Study Design: Comparative study of differing durations of antibiotics for spinal surgery., Objective: To compare rate of infection, duration of hospital stay, days until normal body temperature, and a panel of blood tests after surgery between long-term and short-term administration of antibiotics for spinal surgery using instrumentation., Summary of Background Data: Recent studies have reported that long-term administration of intravenous antibiotics is not necessary to avoid superficial and deep infections. We therefore changed the duration of administration from 9 to 2 days in our lumbar surgery patients., Methods: We examined 135 patients (average age, 64.9 years) who underwent lumbar spinal surgery to insert a pedicle screw system to treat spinal canal stenosis. We administered 2 g of cefotiam daily to 60 patients for 9 days after surgery and to 75 patients for 2 days after surgery. Surgical time, loss of blood, rate of infection, duration of hospital stay, days until normal body temperature, and data from blood analysis (white blood cell count, and C-reactive protein [CRP] level) were statistically compared between the 2 groups., Results: No significant differences in intraoperative measures of surgical invasion were observed between the 2 groups (surgical time, 209 vs. 220 minutes; blood loss, 530 vs. 576 mL; blood transfusion, 344 vs. 380 mL for the long-term and short-term groups, respectively). No acute infections occurred in either group. However, the duration of hospital stay (20.7 days), time until normal body temperature (5.1 days), and CRP level (2.23 mg/dL) at day 7 after surgery were significantly less in the short-term group than those in the long-term group (27.9 days, 6.8 days, and 3.13 mg/dL, respectively; P < 0.05)., Discussion: These results indicate that short-term intravenous administration of antibiotics did not elevate the infection rate after spinal surgery using instrumentation. However, long-term administration of antibiotics prolonged the duration of hospital stay, inhibited normalization of body temperature, and elevated CRP levels. Long-term administration of antibiotics may suppress normal, beneficial bacteria, thereby having an adverse effect on patient recovery.

Study Design: Single institution, prospective observation study., Objective: To determine the long-term clinical outcomes of immune-suppressed patients with pyogenic vertebral osteomyelitis (PVO) treated with spinal instrumentation in the setting of active infection., Summary of Background Data: The mainstay of treatment for PVO remains nonoperative. Surgical indications include neurologic compromise, deformity, abscess and failure of medical management. Some authors have been concerned regarding risk of local infection reoccurrence when spinal instrumentation has been placed in the setting of active infection. To our knowledge no long-term follow-up has been reported for this condition., Methods: Thirty-two consecutive immune compromised patients with PVO were treated with debridement and spinal instrumentation in the setting of acute infection at a single institution. Patients were observed by a set protocol and evaluated for reoccurrence of infection at regular intervals for up to 10 years., Results: The 32 patients in our study group had significant medical comorbidities and were immune compromised. All patients were treated with single stage debridement and instrumented fusion during active infection. Twenty-two patients had a full 10 years follow-up without clinical recurrence of the local infection. Four patients died during the observation period, and none had clinic or autopsy evidence of recurrence. One patient developed recurrent infection after 14 months and was successfully treated with repeat debridement and retention of the instrumentation. Although this patient had a chronically infected vascular shunt, he was disease free at final follow-up of 10 years. Four patients had their implants removed for pain, suspected nonunion or suspected recurrent infection. None of these patients had histologic or microbacteriological evidence of injection., Conclusion: The use of spinal instrumentation in immune-compromised patients with PVO is associated with a low risk of long-term recurrent infection.

Study Design: Study of 4 cases of severe coccydynia revealing calcium deposits in the sacrococcygeal and intercoccygeal joints., Objective: To highlight calcium crystal deposition as a cause of sudden-onset coccydynia., Summary of Background Data: Intervertebral disc calcification in the cervical, thoracic, or lumbar spine is well known, but calcifications in the sacrococcygeal or intercoccygeal joints with symptoms have never been reported., Methods: All 4 patients presented with severe, sudden-onset coccydynia. Radiographs of the coccygeal area showed calcific deposits in the sacrococcygeal or intercoccygeal joints. Patients received a short course of oral corticosteroids or steroid injections., Results: Conservative management provided prompt relief in all but one case. In 2, the resolution of the calcific deposits as seen on follow-up radiography was highly suggestive of their apatite origin., Conclusion: Calcium crystal deposition in the sacrococcygeal or intercoccygeal joints can cause coccydynia. Conservative treatment is effective as a first-line approach.

Study Design: A prospective, randomized, double-blind clinical trial., Objective: To compare the effect of ramosetron with that of ondansetron on opioid-based IV patient-controlled analgesia (PCA) related postoperative nausea and vomiting (PONV) in highly susceptible patients after lumbar spine surgery., Summary of Background Data: Optimal postoperative pain management is important to facilitate early mobilization after lumbar spine surgery. Opioid analgesia is associated with a high incidence of PONV. Among the currently available 5-hydroxytryptamine receptor 3 antagonists (5-HT3), ondansetron is being most widely used with unsatisfactory results regarding opioid-based IV PCA related PONV. Ramosetron is a newly developed 5-HT3 antagonist with higher receptor affinity and longer duration of action having theoretical advantage over ondansetron in this setting. However, data to support this view are lacking., Methods: All 94 female nonsmoker patients (aged 18-65 years) were randomly allocated into either ondansetron group (group O, n = 47) or ramosetron group (group R, n = 47). Fentanyl-based IV PCA was administered for 48 hours after surgery. Overall incidence and severity of nausea and incidence of vomiting were assessed for 48 hours after surgery. Secondary measures included: pain intensity and total amount of administered rescue analgesic., Results: Patients' characteristics were similar between the groups. Overall incidence of nausea was similar between the groups; however, moderate to severe degree of nausea was significantly more in the group O (34%) than in the group R (13%) 6 to 24 hours after surgery. Overall incidence of vomiting and use of rescue antiemetic 6 to 24 hours after surgery was significantly lower in the group R (30% vs. 11% and 28% vs. 11%, respectively). Pain scores at 24 to 48 hours after surgery were significantly lower in the group R (31 +/- 25 vs. 13 +/- 15)., Conclusion: Ramosetron was superior to ondansetron in terms of preventing vomiting and reducing the severity of nausea related to fentanyl-based IV PCA, with less adverse events, in patients with high susceptibility, undergoing lumbar spine surgery.

Study Design: A case report and clinical discussion., Objective: To discuss the diagnosis and treatment of Blastomyces dermatitidis in the spine., Summary of Background Data: Blastomycosis, like other fungal organisms, has a nonspecific appearance on radiographs, and is often mistaken for TB or a neoplasm. Nonsurgical treatment of this infection is possible, however, as seen in this case. The difficulty in diagnosing fungal infections often leads to a delay in treatment., Methods: We report on a 37-year-old Arabian woman who presented initially with progressive low back and anterior thigh pain without precipitating trauma. She was found to have 2 draining fistulas. Computed tomography-guided percutaneous drainage of the paravertebral phlegmon yielded purulent material that was pan cultured. The KOH preparation was consistent with a fungal pathogen, which was later identified as Blastomyces dermatitidis by polymerase chain reaction., Results: Radiologic studies of the lumbar spine and sacrum performed revealed extensive involvements with osseous destruction of L2-S1. The destruction was most severe at L3 with mild boney retropulsion at that level. Throughout the patient's treatment course, she complained of mild-to-moderate lower back pain and had no neurologic symptoms. Therefore, surgery was deferred., Conclusion: There are no pathognomonic findings of blastomycosis on magnetic resonance imaging. Fungal osteomyelitis is rarely identified in this country, and blastomycosis is even less often diagnosed. This case illustrates that fungal osteomyelitis should be considered in the radiographic differential diagnosis until a definitive diagnosis is made through biopsy.

Study Design: A retrospective clinical study., Objective: To evaluate the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) as the primary graft material for the surgical treatment of vertebral osteomyelitis., Summary of Background Data: The clinical and radiographic results using allograft, autograft, and vascularized bone flaps for the surgical treatment of osteomyelitis have been previously reported. Despite an expanding body of literature documenting the value of rhBMP-2 in spinal fusion, its application to the management of spinal infection has never before been analyzed., Methods: Twenty patients underwent surgical treatment of vertebral osteomyelitis using rhBMP-2 and were analyzed with a mean follow-up of 40 months (range, 24-53 months). All patients were treated with anterior column debridement and instrumented reconstruction. Four (20%) patients were treated with an anterior approach alone while the remaining 16 (80%) patients underwent circumferential spinal reconstruction. Clinical outcomes were assessed by Frankel grade and Odom criteria. Radiographic fusion was characterized based on thin-section computerized tomography (CT) analysis., Results: Pathogens responsible for infection included Staphylococcus aureus (11; 55%), S. epidermidis (6; 30%), Bacteroides (1; 5%), and polymicrobial species (1; 5%). Infected segments of the spinal column based on region were found to be: thoracic (1; 5%), thoracolumbar (5; 25%), lumbar (11; 55%), and lumbosacral (3; 15%). The mean number of anterior and posterior segments fused was 3.3 (range, 2-5) and 6.5 (range 2-16), respectively. Forty-five percent of the subjects underwent multilevel corpectomies and fusion. All patients demonstrated clinical and radiographic evidence of spinal fusion at the time of follow-up. Patients had stable (14 patients) or improved (6 patients) Frankel grades after surgery. Odom criteria at final follow-up were: excellent (3; 15%), good (12; 60%), fair (4; 20%), and poor (1; 5%). There was no case of persistent or recurrent infection requiring revision surgery., Conclusion: rhBMP-2 is a valuable graft option for the surgical treatment of vertebral osteomyelitis. When dosed in the manner reported, very high rates of fusion are achievable as is eradication of infection.

Study Design: Evaluation of medication ordering errors discovered on an orthopedic/spinal in-patient hospital unit and efforts initiated to reduce them. OBJECTIVE.: In this study the authors aimed to assess the frequency of medication ordering errors and to examine the impact of local measures set forth to reduce their occurrence., Summary of Background Data: Since the release of the 2000 Institute of Health report: "To Err is Human"; in-hospital medical errors have been recognized as being unacceptably high; the consequence being preventable death rates estimated near 125,000 patients per year. The most common of errors are those involving medications., Methods: The study consisted of 2 parts. In part 1, the charts from 82 consecutive patients admitted to the Orthopedic/Spine Surgical Unit were assessed to determine the frequency, type, and potential severity of medication ordering errors. Several programs to reduce such errors were subsequently instituted and included: improved chart surveillance by pharmacists, a newly developed medication/history form given to and reviewed with patients before surgery, in-service education of preoperative nursing staff, patient database form changes, and requests for patients to bring their medications on admission. Part 2, including 87 patients, assessed the impact of these measures., Results: In part 1, medication errors were detected in 62% of orders overall. Of these, 43% were found to be of moderate or high potential for harm. After the institution of the above measures (part 2), overall errors were reduced by 31%; moderate/high risk potential harm was reduced by 64%; and errors of omission were detected twice as often., Conclusion: Medication errors in ordering are common in orthopedics. We found in part 1 that a chart review and patient interview by the pharmacy team can detect and correct these before reaching the patient. Furthermore, we found in part 2 that the risk could be further reduced by the implementation of pharmacist-led: patient education, education of preoperative nursing personnel, improvement of forms used for data collection, and having the patients bring all of their medications on admission.

Study Design: Human nucleus pulposus cells were cultured in alginate beads and activated with IL-1 beta or TNF-alpha, with and without inhibition of p38 mitogen activated protein kinase (p38 MAPK) activity. Cell production of factors modulating the anabolic/catabolic balance of the disc was determined., Objective: To determine the role of signaling through p38 MAPK in nucleus pulposus cell's response to inflammatory cytokines and whether it might be a valid target for the development of molecular therapies for disc degeneration., Summary of Background Data: Multiple factors contribute to intervertebral disc degeneration (IDD), and development of effective therapies depends on understanding the underlying cellular pathophysiology. Interleukin-1 beta and tumor necrosis factor-alpha are implicated in the development of IDD, and p38 MAPK is part of cytokine and mechanical stress signal pathways in other cells. These studies determine whether inhibiting p38 MAPK can decrease factors that negatively affect the metabolic balance and viability of nucleus pulposus cells., Materials and Methods: Degenerated intervertebral disc tissue was obtained from patients undergoing elective surgical procedures. Nucleus pulposus cells in alginate bead culture were exposed to IL-1 or TNF-alpha, with or without p38 MAPK inhibition, and conditioned media analyzed for accumulation of nitric oxide (NO), prostaglandin E2 (PGE2), IL-6, matrix metalloproteinase-3 (MMP-3), and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) through 10 days., Results: Inhibition of p38 MAPK decreased PGE2 in conditioned medium of control, unstimulated cells while not affecting TIMP-1 accumulation. Blocking cytokine activation of p38 MAPK reduced IL-1 and TNF-alpha induced PGE2 and IL-6 accumulation. p38 MAPK inhibition increased the ratio of TIMP-1 to MMP-3 in conditioned medium of cells activated by IL-1 or TNF-alpha., Conclusion: Inhibition of p38 MAPK in cytokine-activated disc cells blunts production of factors associated with inflammation, pain, and disc matrix catabolism. The data support further analysis of these effects on the anabolic/catabolic balance of nucleus pulposus cells and suggest that molecular techniques blocking this signal could provide a therapeutic approach to slow the course of intervertebral disc degeneration.

Study Design: Randomized, placebo-controlled, double-blind, multicenter, Phase IIa study., Objective: To assess the safety and efficacy of recombinant-activated Factor VII (rFVIIa) in major spinal surgery., Summary of Background: Spinal fusion surgery can cause substantial blood loss and blood product transfusions. Recombinant FVIIa is approved for treatment of bleeding in patients with coagulation abnormalities and has been shown to reduce blood loss and transfusion requirements in surgery in patients with no underlying coagulopathy., Methods: Forty-nine patients undergoing fusion of 3 or more vertebral segments were randomized and treated on losing 10% of their estimated blood volume (with total expected surgical blood loss > or = 20%) and received 3 doses (2-hour intervals) of placebo (n = 13) or 30, 60, or 120 microg/kg rFVIIa (n = 12 per group). The primary endpoint was safety. A priori-defined efficacy endpoints included blood loss and transfusion requirements between placebo and each rFVIIa dose group, adjusted for surgery duration, number of segments fused, and estimated blood volume., Results: Serious adverse events did not occur at any greater frequency in any of the treatment groups. One patient (3 x 30 microg/kg rFVIIa) with advanced cerebrovascular disease (undiagnosed, trial exclusion criterion) died 6 days after surgery due to an ischemic stroke. Mean blood loss was as follows: 2270 mL for placebo; 1909, 1262, and 1868 mL for 3 x 30, 3 x 60, and 3 x 120 microg/kg rFVIIa, respectively (differences not statistically significant). Mean adjusted surgical blood loss was as follows: 2536 mL for placebo; 1120, 400, and 823 mL for 3 x 30, 3 x 60, and 3 x 120 microg/kg rFVIIa, respectively (P < or = 0.001). Mean surgical transfusion volume was reduced by 27% to 50% with rFVIIa treatment (not significant). The mean adjusted surgical transfusion volume was reduced by 81% to 95% with rFVIIa treatment (P < or = 0.002)., Conclusion: No safety concerns were indicated for the use of rFVIIa in patients at all doses tested; rFVIIa reduced adjusted blood loss and adjusted transfusions during spinal surgery.

Study Design: Prospective analysis., Objective: To investigate biologic influences of recombinant human bone morphogenetic protein (rhBMP)-2 on intervertebral discs after anular tears., Summary of Background Data: Treatments for intervertebral disc injury or degeneration are unsatisfactory. rhBMP-2, a high-potency osteoinductive and chondroinductive substance, is approved for use in anterior lumbar interbody fusions. rhBMP-2 stimulates the proliferation of rat disc cells and the secretion of extracellular matrix in vitro. In vivo responses in the intervertebral disc after anular tears are rarely studied., Methods: Twenty New Zealand white rabbits received full-thickness anular tears and intradiscal injections of saline (control) and rhBMP-2 0.1 mg with and without coral grafts at L2-L3, L3-L4, and L4-L5, respectively. Three died or had infection. Therefore, 17 underwent radiography and sacrifice at 12 weeks. Spinal sections were stained with hematoxylin and eosin to examine responses to rhBMP-2., Results: Radiographs revealed degenerative changes, such as disc space narrowing and irregularity, subchondral sclerosis, osteophyte formation, and hypertrophy of vertebral endplates in all groups. Degeneration was more frequent and severe with rhBMP-2 with (P < 0.01) and without (P < 0.05) coral than with saline. Two rabbits receiving rhBMP-2 and coral achieved solid interbody bony fusion. New bone formation was noted in 2 controls, in 3 animals treated with rhBMP-2, and in 4 treated with rhBMP-2 and coral. Vascularity and fibroblast proliferation increased with rhBMP-2 (n = 14) and rhBMP-2 with coral (n = 9) compared with control (n = 3; P < 0.01 and P = 0.03, respectively). Inflammatory infiltrates increased with rhBMP-2 (n = 8) compared with control (n = 2; P = 0.03)., Conclusions: Degenerative changes were more frequent and severe in the groups treated with rhBMP-2 with or without coral in radiographic findings. In histopathologic findings, rhBMP-2 promoted hypervascularity and fibroblast proliferation of the intervertebral disc after an anular tear.

Study Design: In vivo study of the effect of an injection of recombinant human osteogenic protein-1 into degenerated discs induced by chondroitinase ABC., Objective: To investigate the efficacy of an injection of recombinant human osteogenic protein-1 to induce the recovery of disc height, and biochemical and histologic repair, in discs degenerated through enzymatic digestion by chondroitinase ABC., Summary of the Background Data: Chondroitinase ABC is currently proposed as a chemonucleolysis agent; however, postchemonucleolysis degeneration is currently unavoidable. Recombinant human OP-1 has been shown to promote extracellular matrix repair in vitro and in vivo., Methods: Fifty-four adolescent New Zealand white rabbits were used. Four weeks after an initial injection of chondroitinase ABC (10 mU/disc), 5% lactose (10 microL/disc) or recombinant human osteogenic protein-1 (100 microg in 10 microL lactose/disc) was injected. Disc heights were monitored radiographically at 2-week intervals, and rabbits were killed at 6, 8, 12, and 16 weeks after the initial chondroitinase ABC injections. The intervertebral discs were subjected to histologic and biochemical analyses., Results: Significant disc space narrowing was observed in both groups 2 weeks after the injection of chondroitinase ABC. In the chondroitinase ABC/lactose group, this narrowing progressed after the vehicle injection and was sustained for up to 16 weeks. In the chondroitinase ABC/recombinant human osteogenic protein-1 group, the disc height index showed a significant increase at 6 weeks (lactose vs. recombinant human osteogenic protein-1; P < 0.01); this recovery was sustained for up to 16 weeks. The proteoglycan content was higher in the chondroitinase ABC/recombinant human osteogenic protein-1 group than in the chondroitinase ABC/lactose group. However, histologic changes, after the recombinant human osteogenic protein-1 injection, were not observed., Conclusions: A single injection of recombinant human osteogenic protein-1 into a rabbit disc dramatically reversed the decrease in disc height induced by chondroitinase ABC chemonucleolysis. The recovery was significant and sustained over the next 12 weeks. The therapeutic effects of both chondroitinase ABC chemonucleolysis and recombinant human osteogenic protein-1 injections should be further explored in higher animals before it is applied to humans.

Study Design: A systematic review of scientific literature., Objective: The study aimed to determine whether bone morphogenetic proteins (BMPs) are more effective in treating bone defects than traditional techniques, such as grafting autologous bone., Summary of Background Data: BMPs were used in several human randomized controlled trials (RCTs). There are both logical arguments and an empirical basis for using RCTs to evaluate the effects of health care interventions and restrict systematic reviews to such a kind of study design., Methods: An electronic search was made in the databases of MEDLINE, EMBASE (through MeSH and Emtree), and the Cochrane Central Register of Controlled Trials, extended to May 31, 2006, with no linguistic restrictions. RCTs that compare bone regeneration achieved through BMPs versus that obtained by traditional methods entered the study., Results: The 17 publications that met the criteria, divided into subgroups by type of bone, were tabulated by salient characteristics and evaluated through the items proposed by van Tulder et al. However, as the studies differed widely (in terms of site, sample size, dosage of active principle, carrier, clinical and radiologic data recording), it was possible to carry out a metaanalysis of clinical and radiologic outcome only for the subgroup that evaluated the vertebrae, where it was observed that BMPs offer a slightly but statistically significant greater efficacy than do traditional techniques., Conclusions: The use of BMPs at the vertebrae can eliminate the need for surgery to harvest autologous bone. The only large study carried out on the other sites suggests that BMPs should be used at a concentration of 1.5 mg/mL to treat fractures of the tibia. However, further RCTs of good methodological quality are advisable so as to clarify the effectiveness of BMPs in clinical practice.

Study Design: In vitro studies on the effects of recombinant human growth and differentiation factor-5 (rhGDF-5) on matrix metabolism of bovine intervertebral disc cells and an in vivo study on the effect of rhGDF-5 in the rabbit anular puncture model., Objective: To determine the reparative capacity of rhGDF-5 on the intervertebral disc., Summary of Background Data: The in vitro and in vivo effects of rhGDF-5, a crucial protein in the developing musculoskeletal system, on repair of the degenerated intervertebral disc remain unidentified., Methods: In vitro, bovine nucleus pulposus and anulus fibrosus cells were cultured with or without rhGDF-5 (100 or 200 ng/mL). On days 7, 14, and 21, the contents of deoxyribonucleic acid and proteoglycan, and the synthesis of proteoglycan and collagen were assessed. In vivo, 16 adolescent New Zealand white rabbits received anular punctures in 2 lumbar discs. Four weeks later, phosphate buffered saline or rhGDF-5 (10 ng, 1 and 100 mug) was injected into the nucleus pulposus. The rabbits were followed up for 16 weeks for disc height, magnetic resonance imaging, and histologic grading., Results: In vitro, rhGDF-5 increased the deoxyribonucleic acid and proteoglycan contents of both cell types significantly after day 14. rhGDF-5 at 200 ng/mL significantly stimulated proteoglycan synthesis (nucleus pulposus: +138%, anulus fibrosus: +24%) and collagen synthesis (nucleus pulposus: +95%, anulus fibrosus: +23%) at day 21. In vivo, the injection of rhGDF-5 resulted in a restoration of disc height, improvement of magnetic resonance imaging scores, and histologic grading scores with statistical significance (P < 0.05-0.001)., Conclusion: A single injection of rhGDF-5 has a reparative capacity on intervertebral discs, presumably based on its effects to enhance extracellular matrix production in vitro.

Study Design: A single-center prospective analysis of cervical epidurograms, using a crossover design., Objectives: To delineate the extent and pattern of spread of epidural contrast during cervical epidural steroid injections. To determine the volume of solution needed for effective cervical epidural steroid injections. To determine the most appropriate neck flexion angles for cervical epidural steroid injections. To determine the relationships between epidural spread, degree of neck flexion, and volume of solution used during cervical epidural steroid injections., Summary of Background Data: The decreased epidural space in the cervical region makes injections here liable to rare, but potentially serious, complications. The lower cervical (C6-C7, C7-T1) levels are thought to be safer because of the increased epidural space here, as compared with higher levels. There is, however, considerable controversy in the scientific literature regarding the levels at which cervical epidural injections should be performed. There is also no consensus regarding the volume of solution needed or the extent of neck flexion required for effective epidural spread. To date, no study has examined these questions., Methods: Patients with lower cervical spine pathology who were referred for cervical epidural steroid injections were randomly assigned to have the injections performed at the C6-C7 or C7-T1 midline level. Volume of solutions used and degree of neck flexion were measured. Characteristics of epidural spread were recorded. Patients requiring repeat injections had the injections performed at the adjacent level with identical volume and angle of neck flexion using a goniometer. Contrast flow characteristics were again recorded. Extent of spread was correlated with the level of injection, volume of injectant, and degree of neck flexion., Results: No major or permanent complications were noted. The contrast was found to spread evenly throughout the entire dorsal cervical epidural space, on a consistent basis, in all cases. At C6-C7, it was found to spread an average of 3.61 +/- 0.84 levels; and at C7-T1, it spread an average of 3.88 +/- 1.01 levels. Using a three-way analysis of variance, the level at which the epidural was performed, the amount of contrast used, and the neck flexion angle did not affect the number of levels spread., Conclusions: In cervical epidural steroid injections performed in the midline at C6-C7 and C7-T1, the contrast consistently covers the dorsal cervical epidural space bilaterally, irrespective of the volume used or neck flexion angle used. This suggests that solutions introduced here would cover the dorsal cervical epidural space. This questions the utility of performing potentially more dangerous injections at higher cervical levels or more invasive procedures, such as the use of epidural catheters.

Study Design: In vivo study of the effect of injection of osteogenic protein-1 (OP-1) on a rabbit anular needle puncture model of intervertebral disc (IVD) degeneration., Objective: To study radiographic, magnetic resonance imaging (MRI), biochemical, and histologic changes in the rabbit IVD after injection of OP-1 into the nucleus pulposus in a needle puncture disc degeneration model., Summary of the Background Data: Growth factors, such as OP-1, have the ability to stimulate synthesis of proteoglycans and collagen in vitro. The in vivo injection of OP-1 into the normal rabbit IVD has increased disc height and proteoglycan content in the anulus fibrosus and nucleus pulposus. However, to our knowledge, no attempts have yet been made to determine the effects of these growth factors in an in vivo model of disc degeneration., Methods: New Zealand adolescent white rabbits (n = 90, 8 for baseline evaluation, 82 at 8 times) received an anular puncture in 2 noncontiguous discs with an 18-gauge needle to induce disc degeneration. Four weeks later, either 5% lactose (10 microL) or OP-1 (100 microg in 10 microL 5% lactose) was injected into the center of the nucleus pulposus. The disc height was followed radiographically for up to 24 weeks after the injections. At the 2, 4, 8, 12, and 24-week times after the injection, rabbits were euthanized, and MRI of the harvested spinal columns was obtained to grade the degeneration. The discs injected with OP-1 or lactose and noninjected discs were subjected to biochemical and histologic analysis. The specimens at the 24-week time were limited to histologic evaluation., Results: The anular puncture with a needle induced a consistent disc narrowing within 4 weeks. The injection of OP-1 induced a restoration of disc height at 6 weeks, which was sustained for the entire experimental period, up to 24 weeks after the injection. The injection of lactose alone did not change the course of disc narrowing over the same time. MRI grading score showed significant differences between the OP-1 and lactose groups at the 8, 12, and 24-week times, suggesting an increase in water content in the nucleus pulposus of the OP-1 group. The proteoglycan content of the nucleus pulposus and anulus fibrosus was significantly higher in the OP-1 group than in the control group. The degeneration grades of the punctured discs in the OP-1 group were significantly lower than those in the lactose group., Conclusion: The results of this study show the feasibility of restoring degenerative rabbit discs by a single injection of OP-1 into the nucleus pulposus. Importantly, the effects of the OP-1 injection on disc height were sustained for up to 24 weeks. The metabolic changes in the cells, following a single injection, might be sustained and, thus, induce long-term changes in disc structure. An efficacy study in large animals is required to show further that the intradiscal injection of OP-1, or bone morphogenetic proteins or growth factors with similar properties would be useful for the structural restoration of the IVD in humans.

Study Design: Prospective, randomized, unblinded study of iliac crest bone graft (ICBG) versus recombinant human bone morphogenetic protein-2/compression resistant matrix (rhBMP-2/CRM)in a posterolateral instrumented fusion procedure., Objectives: Document initial radiographic characteristics, based on computed tomography, with rhBMP-2/CRM for posterolateral fusion at 6 and 12-month intervals., Summary of Background Data: As the acceptance of INFUSE bone graft as an ICBG replacement becomes more widespread, surgeons have begun to study applications for rhBMP-2 in posterior spinal fusion. Preclinical studies have examined variables including carrier composition, rhBMP-2 concentration, and rhBMP-2 dose. Pilot studies have been performed with encouraging initial results., Methods: Patients with single level lumbar degenerative disease were enrolled in a randomized study of ICBG versus rhBMP-2/CRM in a posterolateral instrumented fusion procedure. Computed tomography scans at 6 and 12 months were graded as demonstrating no fusion (grade 1), partial or limited unilateral fusion (grade 2), partial or limited bilateral fusion (grade 3), solid unilateral fusion (grade 4), or solid bilateral fusion (grade 5)., Results: At our institution, 74 patients (38 rhBMP-2/CRM, 36 ICBG) reached minimum 1-year follow-up and were included in this analysis. Mean fusion grade (scale1-5) at 6 months after surgery was 4.35 in the rhBMP-2/CRM group versus 3.09 in the ICBG group (P < 0.0001). At 1 year after surgery mean fusion grade was 4.62 in the rhBMP-2/CRM group versus 3.77 in the ICBG group (P < 0.0023)., Conclusions: These early results are encouraging and suggest a more rapid incorporation and development of the fusion mass with rhBMP-2/CRM than iliac crest autograft in a single level posterior instrumented fusion.

Study Design: A case report is presented., Objective: We report a detailed time-line of disease progression and suppression in a patient with disseminated Coccidioidomycosis of the spine. The importance of consistent and thorough treatment to prevent disease recurrence is underscored., Summary of Background Data: Coccidioides immitis is a dimorphic fungus that lives as a saprophyte in arid, alkaline soils and as a parasite in the tissues of its host. Endemic to the arid soil of the American Southwest and Central and South America, its disease prevalence is increasing. There are 100,000 new infections diagnosed each year, of which 34% are symptomatic. Of the symptomatic individuals 5-10% will develop a serious pulmonary infection and of those that have a serious infection less than 1% will develop chronic pulmonary disease and/or extrapulmonary dissemination., Methods: A 36-year-old black woman with a 3-year history of recent migration to the desert Southwest and a family history of sarcoidosis presented to her primary care physician with shortness of breath and a cough of 2 months' duration. An anterior-posterior radiograph revealed bilateral hilar lymphadenopathy and sarcoidosis was diagnosed. The patient was placed on oral prednisone and progressively worsened. She was referred to the Orthopedic Clinic with a complaint of severe back pain., Results: Plain radiographs of the lumbar spine revealed lytic erosion of the sacral promontory. Computed tomography confirmed the sacral lesion in addition to revealing involvement of the fifth lumbar vertebral body. Over the ensuing years the patient underwent a course of operative and chemotherapeutic therapies. She endured numerous complications of the disease, one of which is being reported for the first time. Control of her disease has been accomplished through radical surgical debridement, spinal stabilization with concomitant local and systemic chemotherapy., Conclusions: The prevalence and distribution of Coccidioidomycosis is increasing as is the likelihood of seeing its often unique and bizarre clinical manifestations and complications. If included in the differential diagnosis, the disease can be recognized earlier and the likelihood of numerous complications can be avoided. Once bony involvement is diagnosed a regimen of aggressive surgical debridement as well as consistent chemotherapy must be employed if remission and/or eradication of the illness are sought.

Study Design: Posterolateral lumbar fusions were performed in nicotine-exposed, New Zealand white rabbits. Animals that developed a pseudarthrosis were then regrafted with no graft, autograft, or osteogenic protein-1 (OP-1)., Objectives: To establish a model of pseudarthrosis repair and to evaluate the ability of OP-1 to induce fusion in this model., Summary of Background Data: OP-1 has been shown to have a 100% fusion rate in an established rabbit fusion model, even in the presence of nicotine, which is known to inhibit fusion., Methods: Forty-four New Zealand white rabbits underwent posterolateral lumbar fusion with iliac crest autograft. To maximize the incidence of pseudarthroses, nicotine was administered to all rabbits. At 5 weeks, the spines were explored, and all pseudarthroses were redecorticated and grafted with no graft, autograft, or OP-1. At 10 weeks, the rabbits were killed and fusions masses were assessed with manual palpation, radiography, computed tomography, and/or histology., Results: Nine rabbits (20%) were lost to complications. Thirty-four (94%) had pseudarthroses on exploration at 5 weeks. By manual palpation at 10 weeks, 1 of 10 (10%) pseudarthroses that received no graft fused, 5 of 12 (42%) pseudarthroses that received autograft fused, and 9 of 11 (82%) pseudarthroses that received OP-1 fused. Computed tomography and histology further characterized the fusion masses., Conclusions: This study establishes a model for treatment of pseudarthroses. OP-1, which has previously been shown to have 100% fusion rate in animal models, outperformed autograft and induced fusion in 82% of rabbits.

Study Design: The effects of bone cement placement, volume, and bone density on the degree of biomechanical reinforcement on cadaveric vertebral bodies were studied using experimentally calibrated detailed finite element models., Objectives: To investigate the efficacy of prophylactic vertebroplasty on intact vertebral bodies with respect to biomechanical recovery and fracture risk reduction., Summary of Background Data: Vertebroplasty is a potentially effective fracture prevention treatment, but the risk of complications due to cement leakage must be minimized. Therefore, the least amount of bone cement required to improve vertebral strengths to low fracture risk levels need to be determined., Methods: Six different polymethyl methacrylate volumes--1, 2.5, 3.5, 5, 7.5 and 9 cm--were virtually implanted into previously validated vertebral body finite element models, following bipedicular and posterolateral vertebroplasty approaches. Stiffness and fracture load of the treated and untreated vertebral body models under uniaxial compression were determined., Results: Greater augmentation effects were observed for vertebral bodies with average quantitative computed tomography densities below 0.1 g/cm injected with polymethyl methacrylate volumes higher than 20% compared to lower injection volumes and higher bone densities, as well as for the bipedicular approach versus posterolateral. Vertebral bodies at high risk of fracture required at least 20% fill of polymethyl methacrylate to improve the mechanical integrity of vertebral bodies to low fracture risk levels, whereas 5% to 15% polymethyl methacrylate volumes were needed for the medium-risk vertebral bodies., Conclusion: Prophylactic vertebroplasty can be effective in reducing fracture risk. However, for the polymethyl methacrylate volume (20%) required for the successful reinforcement of high-risk vertebral bodies, the risk of complications will be as high as that for current vertebroplasty procedure for fracture repair. Therefore, alternative materials have to be investigated for prophylactic vertebroplasty. Furthermore, bipedicular vertebroplasty is the recommended approach due to its higher strengthening effect and easier surgical access than the posterolateral case.

Study Design: A prospective randomized study of the therapeutic effect of intradiscal steroid injection compared to a saline placebo., Objectives: To determine whether intradiscal steroid injection influences the clinical outcome at 1 year in patients with chronic low back pain of discogenic origin., Summary of Background Data: Steroids have been used empirically in the treatment of back pain. They have been used in the epidural space and around nerve roots and have been used as an alternative to chymopapain within the disc. Previous studies have, however, shown variable results., Methods: A total of 120 patients with chronic low back pain of discogenic origin were enrolled in the study. At discography, if they had concordant pain, they were randomized to injection of normal saline or methylprednisolone into the disc space. These patients were prospectively followed up for 12 months, and they were asked to report pain according to a visual analogue score and their Oswestry Disability Index was recorded. The primary outcome measure was determined as a percentage change in disability, and the results were analyzed using independent samples t test. The secondary outcome measure was a change in the pain score, and this was analyzed using the Mann-Whitney U test., Results: There was no significant difference in the primary outcome between the two groups (P = 0.71). The steroid group had a mean change of 2.28 (SE 2.49) in percentage disability, while the saline group had a mean change of 3.42 (SE 1.79). With respect to the change in pain score, there was no significant difference between the two groups (P = 0.72). Those patients who had saline injection had a median change in pain score of 0 (interquartile range -1 to 1), whereas those given steroid treatment had a median change in pain score of 0 (interquartile range -0.25 to 1)., Conclusions: This study demonstrates that intradiscal steroid injections do not improve the clinical outcome in patients with discogenic back pain compared with placebo.

Study Design: A cross-sectional analysis of data obtained from patients with spinal and radicular pain and their spine center treating physicians was performed., Objectives: To identify characteristics of patients treated with opioids that distinguish them from similar patients not treated with opioids in a large population of patients with spine and radicular pain, and to determine the prevalence of opioid use., Summary of Background Data: The use of opioids with patients who have chronic pain remains controversial. The long-term risks and benefits are poorly described. The efficacy of this treatment has not been proved, yet the large majority of pain specialist physicians manage chronic pain with opioids., Methods: Descriptive data from the initial visits of 25,479 patients with spinal pain were reviewed. Patients were grouped according to whether or not opioids were recommended, prescribed, or continued. The prevalence of opioid use and patient characteristics were compared using standard statistical tests., Results: Overall, 3.4% of the patients had opioids included in their plan of care. There was no difference in age, gender, education, or compensation status between the two groups. Patients were more likely to be treated if the duration of their symptoms had been less than 3 months. However, 75% of the patients with opioids in their plan had experienced symptoms longer than 3 months. A greater incidence of objective findings was identified in the opioid group., Conclusions: The authors cannot comment on the prevalence of opioid use because, to the best of their knowledge, no other similar studies are available for comparison.

Study Design: A case report of cervical osteomyelitis possibly associated with a Zenker's diverticulum perforation., Objectives: To present clinical, radiologic, and surgical findings of a cervical osteomyelitis due to a Zenker's diverticulum perforation., Summary of Background Data: A 56-year-old patient was in an intensive care unit for a severe head injury. He was fed via a nasogastric tube. Four months later he developed a pyogenic cervical vertebral infection., Methods: Plain films and magnetic resonance imaging showed a diffuse cervical osteomyelitis. Investigation of his dysphagia revealed a Zenker's diverticulum., Results: After administration of antibiotics and surgical treatment of the diverticulum, the cervical infection resolved. Plain films and magnetic resonance imaging showed healing with vertebral fusion., Conclusions: Cervical osteomyelitis is uncommon. Only one case of direct contamination leading to cervical vertebral osteomyelitis after esophageal perforation has been previously described. Direct contamination of the prevertebral soft tissues by bacteria traveling through the fistula may have occurred. The development of vertebral osteomyelitis in this case is consistent with the hypothesis of direct contamination. Management relies on appropriate antimicrobial therapy and surgical management of the diverticulum. The association of Zenker's diverticulum with vertebral osteomyelitis and discitis is a unique, previously undescribed situation.

Study Design: An established rabbit intertransverse process lumbar fusion model was used to evaluate osteogenic protein (OP)-1 as a potential graft substitute., Objectives: To determine whether OP-1 is effective in producing intertransverse process lumbar fusion in a rabbit model., Summary of Background Data: Autogenous iliac crest bone is the gold standard in grafting material for inducing intertransverse process fusion. However, bone graft substitutes are being considered as supplementary or alternative means to achieve such fusion with less morbidity. Relatively little research has been undertaken to investigate the efficacy of OP-1 in this role., Methods: Single-level intertransverse process lumbar fusions were performed at L5-L6 of 31 New Zealand White rabbits. These were divided into three study groups: autograft, carrier alone, and carrier with OP-1. The animals were killed 5 weeks after surgery. Resultant fusion masses were evaluated by manual palpation, radiography, biomechanical multidirectional flexibility testing, and histology., Results: Seven rabbits (23%) were excluded because of complications. Of the remaining 24 rabbits, 5 (63%) of the 8 in the autograft group had fusion detected by manual palpation, none (0%) of the 8 in the carrier-alone group had fusion, and all 8 (100%) in the OP-1 group had fusion. Radiographs were 55% sensitive and 92% specific for determining fusion. Biomechanical testing results correlated well with those of manual palpation. Histologically, autograft specimens were predominantly fibrocartilage, OP-1 specimens were predominantly maturing bone, and carrier-alone specimens did not show significant bone formation., Conclusions: OP-1 was found to reliably induce solid intertransverse process fusion in a rabbit model at 5 weeks.

Study Design: Case report., Objectives: Successful excision of the mass and identification of the causative agent by histologic and microbiologic studies., Summary of Background Data: Spinal pain, caused by an infective mass, developed in a 39-year-old man 3 months after an epidural injection for low back pain., Methods: Exploratory surgery was performed to remove the mass, and histologic and microbiologic studies were conducted., Results: The inflammatory mass was excised successfully, and several specimens were examined for bacteriologic presence. Histologic examination of the excised specimen showed chronic granulomatous inflammation, and subsequent microbiologic studies cultured an acid- and alcohol-fast bacillus that was later identified as Mycobacterium fortuitum., Conclusion: A review of the literature shows that this is a particularly uncommon micro-organism.

Study Design: Clinical observation of a patient., Objectives: To present the clinical features of an unusual infection of the spine caused by Campylobacter fetus subspecies fetus and to suggest treatment., Summary of Background Data: This is only the second reported case of pyogenic vertebral osteomyelitis caused by Campylobacter fetus subspecies fetus., Methods: A 66-year-old man had pain of the left lower extremity. Radiologic examination revealed an epidural mass associated with destruction of the L5-S1 vertebral bodies., Results: Biopsy of the epidural mass was performed, and culture yielded Campylobacter fetus subspecies fetus. After intravenous antibiotics, oral doxycycline and erythromycin were given for 5 months. At 9 months after antibiotic treatment was completed, the patient's condition was stable., Conclusions: Prolonged oral administration of doxycycline and erythromycin was curative in this patient.

Study Design: Report of a rare case of spinal actinomycosis in a young immunocompetent woman., Objective: To show the difficulties in diagnosing spinal actinomycosis., Summary of Background Data: Spinal actinomycosis is rare and usually occurs as a result of a contiguous (abdominal, pelvic, or thoracic) spread of the infection. This localization represents less than 5% of the infectious sites and was mainly, before the penicillin era, a postmortem discovery., Methods: A case is reported of a 34-year-old Algerian woman who had fever, persistent cough, right-side thoracic pain, and progressive severe back pain. Radiographs, computed tomographic scan, and magnetic resonance imaging demonstrated lytic areas on the vertebral bodies of T11 and T12 and a paravertebral mass, without disk involvement. A surgical biopsy of T12 and the paravertebral abscess was performed., Results: Presence of characteristic sulfur granules and gram-positive filamentous bacteria in surgical biopsy tissues and isolation of Actinobacillus actinomycetemcomitans in cultures led to the diagnosis of vertebral actinomycosis. The patient was virtually free of pain and fever after a 3-month regimen of ofloxacin and rifampicin (Rifadine, Marion-Merell, France) and was without recurrence after 18 months of follow-up., Conclusions: Actinomycosis of the spine, caused by the spread of a paraspinal abscess, is extremely rare. The previously poor prognosis has been transformed by antibiotics.

Study Design: A case of paraspinal abscess formation from Haemophilus paraphrophilus is presented., Objectives: To describe a case of paraspinal abscess formation from H. paraphrophilus, a fastidious commensal organism of the mouth and pharynx. A precise bacteriologic identification can be difficult; techniques for such identification are discussed., Summary of Background Data: Spinal abscess caused by H. paraphrophilus is unusual and can be very difficult to diagnose., Methods: The etiology, clinical presentation, technical examinations, and treatment are reviewed., Results: Prolonged antibiotic treatment was curative, although surgery was considered., Conclusions: Bacteriologic diagnoses in these rare infections are difficult. Antibiotic therapy was curative in the patient described.

Study Design: Retrospective chart review of 44 cases., Objective: To describe the clinical usage of the erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis., Summary of Background Data: The erythrocyte sedimentation rate is often used to determine the efficacy and duration of treatment in pyogenic vertebral osteomyelitis. Although consensus and anecdotal reports support this notion, no detailed review of the erythrocyte sedimentation rate response in conservative treatment of pyogenic vertebral osteomyelitis has been made, to date., Methods: For 44 patients with pyogenic vertebral osteomyelitis who had erythrocyte sedimentation rate testing at or before the time of diagnosis and at least twice during the next month, the clinical findings and results of the erythrocyte sedimentation rate testing were reviewed., Results: Of 18 cases with no significant fall in the erythrocyte sedimentation rate during the first month, 9 (50%) failed conservative treatment. Conversely, of the 26 cases with a good erythrocyte sedimentation rate response during the first month, three (12%) were clinical failures. However, a rapid decline of the erythrocyte sedimentation rate (> 50% in the first month) is rarely seen in treatment failure. In addition, approximately 2 weeks after antibiotic treatment, 19 of 32 were actually higher than at the time of diagnosis, but went on to clinical cure without surgery. The erythrocyte sedimentation rate, in combination with the patient's age and immune status, predicted the success of antibiotic treatment, in most cases. The erythrocyte sedimentation rate response alone during the first month was not a clear predictor of success., Conclusions: Although the erythrocyte sedimentation rate does correlate well with response to treatment as a general rule, care must be taken in interpretation of a persistently elevated or even rising erythrocyte sedimentation rate as an isolated clinical finding.

Study Design: A case report from one of the longest follow-up studies of survivors with spinal hydatid disease. This patient was treated with a combination of albendazole and praziquantel chemotherapy; the results of this form of treatment are reported., Objectives: To demonstrate the efficacy of combination albendazole and praziquantel drug treatment for spinal hydatidosis., Summary of Background Data: Although echinococcal infestation in humans is a world-wide problem, it is rarely seen in the United Kingdom. Between 1% and 2% of all cases involve bone, and 50% of these involve the spine. The condition has a reported mortality rate of more than 50%. The average length of survival of patients with echinococcal infestation in Britain after the onset of symptoms is 5 years, and the average age at death is 41 years., Methods: The patient in this report had undergone multiple spinal debridement operations alongside internal fixation and presented with increasing paraparesis from recurrent disease. Surgery for disease recurrence carries a high risk of mortality. The patient was treated with a preoperative combination of albendazole and praziquantel drug therapy, a novel combination for this condition., Results: Response to treatment was monitored clinically, biochemically, and with serial computed tomography. No serious side effects were observed. Results were very encouraging. After 2 months of treatment she had improved and was able to walk with the aid of a walking frame; therefore, surgery was deferred., Conclusion: The combination of albendazole and praziquantel drug therapy appears to be effective in the conservative treatment of patients with inoperable spinal hydatidosis.

Study Design: This study demonstrated the therapeutic value of chemonucleolysis with chondroitinase ABC to canine intervertebral disc displacement., Objectives: To determine the efficacy of Chondroitinase ABC in the management of canine intervertebral disc displacement., Summary of Background Data: No previous study has assessed the chemonucleolysis with chondroitinase ABC in the displaced discs. The changes of intervertebral disc syndrome were evaluated in this study., Methods: Fifty-nine dogs with symptoms and signs of intervertebral disc displacement were treated with Chondroitinase ABC by a single intradisc injection. The changes in symptoms and signs of disc herniation in the dogs were followed from 7 days to 3 years after treatment., Results: Forty-eight dogs were evaluated for the efficacy of the chemonucleolytic treatment with chondroitinase ABC. At 1 week after injection, 45 of 48 dogs showed some improvement in symptoms and signs. No adverse reactions were observed. There was no recurrence of symptoms in nine dogs who were observed from 14 months to 3 years after injection., Conclusion: Chemonucleolytic treatment with chondroitinase ABC is an effective and safe method for the management of canine intervertebral disc displacement.