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BACKGROUND: Chronic neck pain is a common clinical problem. It has long been considered that degenerative cervical disc is an important source of chronic neck pain. In the clinic, cervical discography is thought to be a useful and safe method to distinguish aging discs from pathological discs, and the probability of complications caused by it is really rare. However, once complication occurs, it is likely to cause fatal consequences to patients. Therefore, accurate judgment and effective treatment are crucial. CASE SUMMARY: A 45-year-old female was admitted to the department with a 5-year history of severe neck pain, dizziness, and tinnitus. In order to find the diseased disc, analgesic discography was performed on C4/5 and 6/7 discs successively. Unfortunately, Discitis with an epidural abscess was caused during the procedures. With the help of magnetic resonance imaging, an accurate diagnosis was made and an urgent anterior cervical operation was given subsequently. The patient ultimately recovered well. CONCLUSION: Discitis with epidural abscess is a rare complication after cervical discography, which needs accurate diagnosis and effective antibiotic treatment.

Background Surgical treatment of pyogenic discitis and vertebral osteomyelitis (PDVO) is indicated for neurologic deficit, spinal instability, unknown pathogen, poorly controlled infection, or intractable pain. Although the posterior-only approach has been proved a safe, effective procedure that minimizes the risks and complications of anterior or staged surgery, parenteral antibiotic treatment for 4–6 weeks postoperatively is still necessary. We hypothesized that antibiotic-impregnated bone graft used in an all posterior approach could result in infection control and shorten the postoperative course of pyogenic discitis and vertebral osteomyelitis. Methods 21 consecutive patients with pyogenic discitis and vertebral osteomyelitis of the lumbar or thoracic spine were treated with transforaminal interbody debridement and fusion (TIDF) with antibiotic-impregnated bone graft (AIBG) between March 2014 and January 2017. Minimum follow up was 2 years. Outcomes included visual analog scale (VAS) back pain, ASIA scale for neurological status, kyphotic angle correction, fusion status, and functional outcome using Kirkaldy-Willis criteria, and c-reactive protein (CRP) levels. CRP levels from pre-op, immediately post-op, and 1, 2, 4 & 6 wks post operatively and the duration of treatment with postoperative IV antibiotics in our patients was compared to our previous case series in which TIDF was performed without AIBG. Results Surgical treatment for PDVO resulted in clinical improvement and adequate infection control. There was no difference in pre-op CRP levels between the two groups. Despite shorter post-op IV antibiotic duration (Mean 21.0 d vs 39.8 d), the AIBG group had a stable decline in CRP levels and continued to decrease at 1, 2, 4 & 6 weeks, with significantly lower CRP levels at 6 weeks compared to bone graft without antibiotics. VAS scores improved from a mean of 7.2 to 2.3 one month postoperatively. Patients who had increased kyphotic angles had an average angle correction of 7.9° at last follow-up. Conclusion The technique of TIDF combined with AIBG can achieve local infection control with faster reduction in CRP, leading to shorter antibiotic duration for pyogenic discitis and vertebral osteomyelitis

Introduction Surgical treatment of pyogenic discitis with vertebral osteomyelitis (PDVO) is indicated for neurologic deficit, spinal instability, unknown pathogen, poorly controlled infection, or intractable pain. Although the posterior-only approach has been proved a safe, effective procedure that minimizes the risks and complications of anterior or staged surgery, parenteral antibiotic treatment for 4-6 weeks postoperatively is still necessary. We hypothesized that antibiotic-impregnated bone graft used in an all posterior approach could result in infection control and shorten the postoperative course of pyogenic discitis and vertebral osteomyelitis. Patients and Methods 21 consecutive patients with pyogenic discitis and vertebral osteomyelitis of the lumbar or thoracic spine were treated with transforaminal interbody debridement and fusion (TIDF) with antibiotic-impregnated bone graft (AIBG) between March 2014 and January 2017. Minimum follow up was 2 years. Outcomes included visual analog scale (VAS) back pain, ASIA scale for neurological status, kyphotic angle correction, fusion status, and functional outcome using Kirkaldy-Willis criteria, and c-reactive protein (CRP) levels. CRP levels from pre-op, immediately post-op, and 1, 2, 4 & 6 wks post operatively and the duration of treatment with postoperative IV antibiotics in our patients was compared to our previous case series in which TIDF was performed without AIBG. Results Surgical treatment for PDVO resulted in clinical improvement and adequate infection control. There was no difference in pre-op CRP levels between the two groups. Despite shorter post-op IV antibiotic duration (Mean 21.0 d vs 39.8 d), the AIBG group had a stable decline in CRP levels and continued to decrease at 1, 2, 4 & 6 wks, with significantly lower CRP levels at 6 weeks compared to bone graft without antibiotics. VAS scores improved from a mean of 7.2 to 2.3 one month postoperatively. Patients who had increased kyphotic angles had an average angle correction of 7.9° at last follow-up. Eighty-one percent of patients (17/21) had good to excellent functional outcomes. Conclusion TIDF combined with AIBG can achieve local infection control with faster reduction in CRP, leading to shorter antibiotic duration for pyogenic discitis and vertebral osteomyelitis

Study Design Retrospective review of patients who had pyogenic discitis and were managed surgically. Purpose To analyze the bacteriology, pathology, management and outcome of pyogenic discitis of the lumbar region treated surgically. Overview of Literature Surgical management of pyogenic discitis is still an infrequently used modality of treatment. Methods A total of 42 patients comprised of 33 males and 9 females who had pyogenic discitis with a mean age of 51.61 years (range, 16-75 years) were included in this study. All the cases were confirmed as having pyogenic discitis by pus culture report and histopathological examination. The mean follow-up period was 41.9 months. Results Debridement and posterior lumbar interbody fusion with autologous iliac bone graft was done in all cases. Thirteen (30.95%) patients had other medical co-morbidities. Five cases had a previous operation of the spine, and three cases had a history of vertebral fracture. Three patients were operated for gynaecological problems, and four cases had a history of urological surgery. L4-5 level was the most frequent site of pyogenic discitis. The most common bacterium isolated was Staphylococcus aureus (S. aureus). Radiologically good fusion was seen in the majority of patients. Conclusions Pyogenic discitis should be suspected in people having pain and local tenderness in the spinal region with a rise in inflammatory parameters in blood. The most common bacterium was S. aureus, but there were still a greater number of patients infected with other types of bacteria. Therefore, antibiotics therapy should be started only after isolating the bacteria and making the culture sensitivity report.

Purpose. To assess the treatment outcome for disc infection in 35 patients. Methods. Records of 23 men and 12 women aged 36 to 62 (mean, 43) years who underwent treatment for pyogenic discitis after open discectomy were reviewed. All patients had single-level disc herniation of L4–5 (n=28) or L5-S1 (n=6), except for one who had 2-level disc herniation of L4-S1. Single antibiotic was given one day prior to discectomy and continued for 2 days. All excised discs were found to be sterile. Discitis was classified into acute (n=26), subacute (n=7), and chronic (n=2). Antibiotic therapy was started immediately when the clinical diagnosis was made. 31 patients were treated with antibiotics alone; the remaining 4 underwent surgery entailing simple posterior superficial wound drainage (n=1), anterior radical surgery (n=2), or posterior instrumentation and posterolateral fusion for post-discectomy syndrome (n=1). Six of the 12 patients who had percutaneous disc space aspiration underwent disc space irrigation. Results. The initial symptoms included mild-to-moderate fever (n=4), severe back pain (n=27), back muscle spasms (n=26), back pain radiating to the limb (n=2), Gower sign (n=11), and a draining wound (n=1). The wound aspirates of the 12 patients grew organisms, although blood cultures were negative in all. After antibiotic therapy, symptoms gradually subsided in parallel with normalisation of white blood cell count and inflammatory markers. Surgery was indicated only when symptoms worsened and the disease progressed. Spontaneous intercorporal fusion did not occur. Conclusion. Early diagnosis and treatment with appropriate antibiotics is important for post-discectomy discitis.

Despite improved diagnostic modalities for psoas abscesses, the optimum management strategy is not uniform. A 67-year-old man presented with bilateral psoas abscesses secondary to L1-L2 pyogenic discitis. On contrast-enhanced CT, the largest of these abscesses measured 13 × 14 × 33 mm on the right. The patient developed sepsis caused by Klebsiella pneumonia. There were no signs of improvement after 3 weeks of systematic antibiotic administration. We performed surgical drainage of bilateral psoas abscesses by retroperitoneoscopy. Intraoperative laparoscopic ultrasound was useful to determine abscess location in the muscles prior to drainage and confirm no residual abscesses after drainage. The patient was afebrile 3 days later, and his clinical symptoms resolved. Retroperitoneoscopic drainage may represent a feasible minimally invasive therapeutic option for psoas abscess, and intraoperative laparoscopic ultrasound has the potential to increase the safety and efficacy of this surgical procedure.

A 35-year-old male who had been receiving conservative treatment for L4 isthmic spondylolisthesis suffered from pyogenic spondylodiscitis in the degenerative L4/L5 intervertebral disc space, which could be identified by comparison with previous images. Symptoms improved with conservative antibiotic treatment. Neovascularization may occur in the annulus fibrosus of a degenerative intervertebral disc, which may increase the risk of hematogenous infection, leading to “discitis” even in adults.

INTRODUCTION Abiotrophia species have been referred to as nutritionally variant streptococci because of their fastidious nutritional requirements for growth. Abiotrophia species are difficult to identify with conventional solid culture. PRESENTATION OF CASE A 48-year-old woman was admitted to our hospital with severe low back pain and body temperature of 38.2 °C. Magnetic resonance imaging revealed edema and contrast enhancement of the L4 and L5 vertebral bodies with high signal intensity in the L3-4 and L4-5 intervertebral discs on the T2-weighted images. The patient underwent needle biopsy of the L3-4 disk. Cultures of disk biopsy samples and blood yielded gram positive cocci in short chains with scanty growth on chocolate agar. Further subculture with supplemented medium and subsequent 16S ribosomal RNA gene sequencing identified the pathogen as Abiotrhophia adiacens. The patient was treated with intravenous ampicillin. At 6-month follow-up, the patient was free of symptoms. DISCUSSION Causative microorganisms remain unidentified in 25–40% of spinal infection cases. Abiotrophia species grow poorly on conventional solid media, and require pyridoxal or thiol group supplementation. Use of Brucella HK agar or GAM agar plate is helpful for detection of Abiotrophia species. We first confirmed the diagnosis by direct identification of Abiotrophia adiacens from infected disk. Abiotrophia species are one of the major pathogens of infective endocarditis accounting for 5% of cases. Considering their fastidious nature, it is likely that most cases of Abiotrophia discitis are falsely classified as culture-negative discitis; therefore, their role in pyogenic discitis may be underestimated. CONCLUSION Subculture using nutritionally supplemented media is crucial for their identification.

S状結腸癌術後に発症した稀な合併症と考えられる化膿性椎間板炎の1例を経験したので報告する.症例は56歳,女性.下血を主訴に来院し,諸検査にてS状結腸癌と診断. S状結腸切除術を施行した.術後第4病日から38°C～40°C台の発熱が持続し,第12病日から体動時の腰痛を認め感覚障害も伴い徐々に歩行困難が出現した.その間,各種検査を施行したが発熱の原因は確定できず腰椎単純X線検査においても異常所見はなかった.第20病日,腰椎MRIを施行したところL5/S1の椎間板に変性を認め,シンチグラフィーにて同部位の異常集積像があり,化膿性椎間板炎と診断した.保存的治療にて軽快し退院となった.第60病日の単純X線検査では椎間腔の狭小化および椎体の不整像が出現していた.術後に発熱,腰痛を伴う際は本症を念頭に置き,単純X線検査のみでは早期診断が困難なことからMRIなどの積極的な検査が必要である.

Sir, The recent report on "management of pyogenic discitis" is very interesting [1]. Devkota et al. [1] noted that "antibiotics therapy should be started only after isolating the bacteria and making the culture sensitivity report." In fact, the identification of the pathogen is very important for the proper management of infective discitis. However, an organism negative case remains an important problem. This is a big challenge and can be often seen in the clinical practice. According to the report by Kehrer et al. [2], more than 20 % of cases had negative culture results. In the tropical world, most of those cases are usually managed as tuberculous discitis and a long term antibiotic treatment with close follow-up is suggested. As Kehrer et al. [2] noted; "the overall incidence of Staphylococcus aureus and culture negative cases of spondylodiscitis increased and remained highest among the elderly."

The optimal management of pyogenic discitis is not agreed on. No randomized clinical trials of short-course or oral antibiotic regimens have been published to date. To shed light on this issue, we reviewed the management of patients admitted for pyogenic discitis to one of 12 networked rheumatology departments. In this cross-sectional observational study, each department included the first ten patients admitted starting in January 1997 for treatment of pyogenic discitis. One hundred ten patients met the inclusion criteria, 67 men and 43 women, with a mean age of 60.6 ± 13.7 years (range, 17–86 years). Mean time from symptom onset to diagnosis was 39.6 ± 39.8 days (range, 24 h–240 days). Blood cultures were positive in 47.3% of patients, and the percutaneous discal and vertebral biopsy in 63.6% of cases; these two investigations identified the causative organism in 79 cases (72.8%). Mean duration of the rheumatology department stay was 31.3 ± 14.1 days (range, 4–78 days). Antibiotics were given intravenously to 103 (93.6%) patients, for a mean of 25.5 ± 17.6 days (range, 4–124 days); duration of intravenous antibiotic therapy was longer than 4 weeks in 36.5% of patients. Only seven (6.4%) patients received primary oral antibiotics with no parenteral antibiotics. One hundred patients were given oral antibiotics at the same time as and after intravenous antibiotics, for a mean duration of 87.2 ± 43.6 days (range, 20–278 days); Bracing was used in 98 (89.1%) patients. Although antibiotic selection was rational and in agreement with current recommendations, wide differences were noted across centers regarding intravenous treatment duration, hospital stay duration, and total treatment duration.

Coexistence of aortic lesions and discitis is uncommon but potentially fatal if the diagnosis is not made promptly. We report the case of a 71-year-old patient with an infected prosthetic graft of the abdominal aorta impinging on the left ureter and accompanied with lumbar discitis. This triad has not been reported previously. Other unusual features in this patient were the circumstances of onset and the development of the infection in a vascular prosthetic graft. The medical and surgical treatment is discussed.

Sir/Madam, We thank Beuy Joob for commenting on our recent report on "Surgical Management of Pyogenic Discitis of Lumbar Region [1]." We were able to get 100% culture positivity in the 42 cases probably because of open surgical extensive debridement of the disc space during posterior lumbar interbody fusion. Discitis due to tuberculosis (TB) and other causes were excluded, and only those that are managed surgically were included. The clinically and histopathologically confirmed TB discitis were not included. We also did histopathological analysis of the infected materials in all cases, which showed evidence of acute infection without granuloma formation. Obtaining proper representative sample for culture is of paramount importance in getting positive result. In case of culture negativity, simultaneous histopathological analysis of the material could help the clinician in differentiating pyogenic discitis from tuberculous discitis by the absence of granuloma. So, the tissue specimens should be subjected to histological analysis as well. It is even more important in tropical regions to diagnose and treat pyogenic discitis from TB, to avoid the major complications due to long term empirical anti-tuberculous drug therapy.

A 55-year-old-male patient had acute lower back pain and radiculopathy with high spiking fever, which indicated pyogenic discitis. Intravenous antibiotics were administered but a high spiking fever and elevated laboratory findings indicated an infection. Therefore, surgery was performed. However, histological diagnosis revealed tophaceous gout. A diagnosis of spinal gout should be considered when there are clinical presentations of acute back pain and fever, especially in patients with acute back pain and a prior history of hyperuricemia or gout.

Study design : To present preliminary results of PLIF (Posterior lumbar interbody fusion) and pedicle screw fixation in the lumbar pyogenic discitis. Objectives : To evaluate the advantages and effects of PLIF and posterior instrumentation over recurrence of infection in lumbar pyogenic discitis which are resistant to antibiotics. Summary of Literature Review : To the date, anterior removal of the focus followed by interposing autogenous bone graft without additional instrumentation and postoperative long-term immobilization has been the standard operative procedure. Materials and Methods : 10 consecutive patients who had lumbar pyogenic discitis were treated by posterior approach from October 1997 to March 1999. Results : Based on MRI or CT finding, 9 solid union at 3~4 months after operation and 1 suspicious union at 1 year after operation were observed. The mean preoperative lordotic angle of the affected segments was 9°, compared to 20°after postoperation and 17°at last follow up. As for functional result of Kirkaldy-Willis, outcome was excellent in 3, good in 5, fair in 2, none poor case. The duration of postoperative bed rest period was an average of 3 days. Conclusions : PLIF with instrumentation in lumbar pyogenic discitis is a useful treatment in posterior epidural abscess,coexistent spinal stenosis and lower lumbar level where anterior fixation is impossible. It is especially indicated in the case of scanty antevertebral abscess with minimal bone destruction. Its main advantage is early ambulation.