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Pneumocystis jirovecii, formerly known as Pneumocystis carinii, is an atypical fungal pathogen best known for causing Pneumocystis jirovecii pneumonia (PCP). The epidemiology of PCP is changing such that patients without HIV infection now comprise the largest subset of individuals diagnosed with PCP. While those with hematologic malignancies and organ transplants are at greatest risk for non-HIV-related PCP, this review will focus on PCP in patients with solid tumors. They are at risk for PCP due to their chemotherapy regimens and use of steroids in the management of various complications of treatment, and possibly because of the immunosuppressive effect of the cancer itself. In particular, patients with solid tumors being treated for metastatic spinal cord compression are at great risk for PCP. Patients with solid tumors and PCP face greater mortality than those with HIV infection. Multiple reviews have attempted to describe the ideal regimen of corticosteroids for metastatic spinal cord compression, but there is little consensus. We present 2 cases of patients with metastatic spinal cord compression due to prostate cancer undergoing radiation therapy and treatment with corticosteroids. These cases highlight the difficulties in predicting the length of corticosteroid therapy and the dangers that patients face without appropriate prophylaxis. This article will also provide a review of the current guidelines for PCP prophylaxis in patients undergoing treatment for metastatic spinal cord compression. We recommend empiric treatment with trimethoprim-sulfamethoxazole or dapsone in those patients with a sulfa allergy in all patients with solid tumors when any high-dose steroids are started for the treatment of metastatic spinal cord compression. Further research is needed to assess the epidemiology of PCP in patients with solid tumors and additional trials are necessary to refine PCP prophylaxis.

Disseminated fungal infections are often seen in immunocompromised patients. Here we present a case of a previously healthy woman presenting with cervical myeloradiculopathy found to have two separate fungal infections in the setting of depressed CD4 cell counts and a genetic mutation predisposing to invasive fungal infections., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Although tuberculosis is rare in the west, in recent years, it's becoming more and more common in China. Intraspinal tuberculoma is extremely rare, but it's an important cause of morbidity. Magnetic resonance imaging scanning is an effective method for the diagnosis of intraspinal tuberculoma., Case Description: This case report shows an intraspinal tuberculoma with giant paraspinal abscesses in a 28-year-old female patient with subacute progressing neurologic deficit. L1-L5 laminectomy was performed, followed by extensively excision of intraspinal and paraspinal lesion. Antituberculous treatment was carried out after pathologic diagnosis. An excellent clinical outcome was obtained. Within 24 hours of the surgical procedure, muscle weakness in both lower extremities started to improve. Three days later, the patient felt muscle strength recovered significantly, with grade 4/5 in the lower limbs in 2 weeks. Six weeks later, the patient was able to walk without assistance., Conclusions: The case was treated by surgical excision of an intraspinal and a paraspinal lesion followed by normal quadruple antituberculous therapy. Although intraspinal tuberculoma is a rare entity, it can be effectively diagnosed on the basis of magnetic resonance imaging scanning and treated by the combination of medical and surgical treatments., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Many studies about the characteristics of spinal tuberculosis (STB) have been published, but none has investigated the predictive factors for lower-extremity motor or sensory deficits (LMSD) in patients with STB.The objective of this study was to find early predictive factors for LMSD and evaluate surgical results of patients with STB.From 2001 through 2010, 329 patients with STB were treated in our department and surgical treatment was performed in 274 patients. The factors assessed included age, sex, duration of symptoms, worsening of illness, clinical symptoms, clinical signs, imaging characteristics, kyphotic angle, Oswestry disability index (ODI), and visual analogue scale (VAS) scores.Of the 329 patients studied, 164 presented with LMSD (the LMSD group), of which 93 patients (28.3%) had motor deficits and 177 patients (53.8%) had sensory disturbance. The other 165 patients were included in the control group (the No LMSD group). Using univariate logistic regression analysis, we found that the sex (P = 0.042), age (P = 0.001), worsening of sickness (P = 0.013), location (P = 0.009), and spinal compression (P = 0.035) were the risk factors of LMSD. Furthermore, the multivariate logistic regression analysis indicated that age (OR = 1.761, 95% CI: 1.227-2.526, P = 0.002), worsening of sickness (yes vs no: OR = 1.910, 95% CI: 1.161-3.141, P = 0.011), location (T vs C: OR = 0.204, 95% CI: 0.063-0.662, P = 0.008), and spinal compression (yes vs no: OR = 1.672, 95% CI: 1.020-2.741, P = 0.042) were independent risk factors of LMSD. Surgical treatment was performed in 274 patients. The kyphotic angle improved from 25.8 ± 9.1° preoperatively to 14.0 ± 7.6°, with a mean correction of 11.8 ± 4.0°, and a mean correction loss of 1.5 ± 1.8° at final visit. There were significant differences between the preoperative and the final ODI and VAS scores in both groups (P < 0.001 and P < 0.001, respectively).Spinal tuberculosis with cervical or lumbar vertebra involvement among the elder patients with a history of worsening of illness and spinal compression tended to cause LMSD, such as motor deficits or sensory disturbance. We should implement an appropriate treatment regimen to prevent exacerbation of STB such as operation, which can achieve thoroughness of debridement, adequate spinal stabilization, and better functional recovery.

Background Context: Propionibacterium acnes is a gram-positive and facultative anaerobe bacillus that is found within sebaceous follicles of the human skin and recognized as a cause of infections after spinal surgery. To our knowledge, there has been no previously reported case of symptomatic compressive chronic inflammatory epidural mass caused by P. acnes in a patient with no prior spinal procedures., Purpose: This study aimed to describe a case of primary spinal infection by P. acnes., Study Design: This study is a case report of a condition not previously described in the literature., Methods: We present the history, physical examination, laboratory, radiographic, and histopathologic findings of a chronic inflammatory epidural mass caused by P. acnes in an immunocompetent adult male with no history of spinal surgery., Results: A 51-year-old man presented to our clinic with sudden onset bilateral lower extremity weakness, inability to ambulate, and urinary retention. His past clinical history was remarkable only for hernia and left knee surgery but no spinal surgery. A year earlier, he had an infected draining abscess of the right axilla that was successfully managed medically. At presentation, his serum erythrocyte sedimentation rate and C-reactive protein were moderately elevated. Pan-spine magnetic resonance imaging was notable for a circumferential epidural mass from C5 to T6. He underwent emergent decompression; the mass was removed and sent for culture and pathologic evaluation. Cultures from all three specimens collected during surgery grew P. acnes, and the patient was successfully managed on intravenous ceftriaxone, while pathology revealed a chronic inflammatory reactive process., Conclusions: This is the first reported case of a primary spinal mass with chronic inflammatory features caused by P. acnes. In cases of epidural mass of unknown origin, both pathologic specimens and cultures should be obtained as slow-growing organisms may mimic oncologic processes., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: We describe a patient who had cervical spine osteomyelitis caused by Blastomyces dermatitidis that resulted in cord compression and cervical spine instability., Case Presentation: A 25-year-old Hispanic woman presented with fever, sweats, neck pain, and an enlarging neck mass with purulent discharge after sustaining a C6 vertebral body fracture. Magnetic resonance imaging confirmed C6 vertebral osteomyelitis, demonstrated by vertebral body destruction, cervical spine instability, prevertebral abscess, and spinal cord compression. She underwent C6 anterior cervical corpectomy and fusion, with fungal cultures confirming Blastomyces dermatitidis., Conclusions: Anterior cervical corpectomy and fusion successful debrided, decompressed, and restored cervical spine stability in a patient with vertebral osteomyelitis caused by Blastomyces dermatitidis. The patient was subsequently treated with a 1-year course of itraconazole and had no recurrence of infection 4 years postoperatively.

Blastomycosis is a rare fungal infection that primarily produces acute lung infections but may disseminate to multiple sites, including the spine. Once vertebral involvement occurs, an untreated infection may result in vertebral body destruction and paraspinal and epidural abscess formation followed by neurologic injury and loss of structural integrity of the spine. We report the case of a 30-year-old man who had pulmonary blastomycosis (treated with oral itraconazole for 6 months) and presented with a 2-month history of mild thoracolumbar back pain and numbness and tingling in the lower extremities, but no neurologic deficits. Imaging revealed a destructive lesion of T11 with an extensive paravertebral and retropleural abscess tracking a spinal level above and below with extension into the spinal canal. The patient underwent incision and drainage, culture procurement and corpectomy of T11 with autogenous rib graft in a titanium cage, and, 1 week later, posterior fusion and instrumentation. Cultures were positive for Blastomycosis dermatitidis. Oral itraconazole was continued. Blastomycosis that disseminates to the spine may cause serious neurologic and structural complications. In most cases, long-term use of antifungal medication eradicates the infection. Should medical treatment fail, however, surgery is a useful option.

The most dreaded neurological complications in TB spine occur in active stage of disease by mechanical compression, instability and inflammation changes, while in healed disease, these occur due to intrinsic changes in spinal cord secondary to internal salient in long standing kyphotic deformity. A judicious combination of conservative therapy and operative decompression when needed should form a comprehensive integrated course of treatment for TB spine with neurological complications. The patients showing relatively preserved cord with evidence of edema/myelitis with predominantly fluid collection in extradural space on MRI resolve on non-operative treatment, while the patients with extradural compression of mixed or granulomatous nature showing entrapment of spinal cord should be undertaken for early surgical decompression. The disease focus should be debrided with removal of pus caseous tissue and sequestra. The viable bone should only be removed to decompress the spinal cord and resultant gap should be bridged by bone graft. The preserved volume of spinal cord with edema/myelitis and wet lesion on MRI usually would show good neural recovery. The spinal cord showing myelomalacia with reduced cord volume and dry lesion likely to show a poor neural recovery. The internal kyphectomy is indicated for paraplegia with healed disease. These cases are bad risk for surgery and neural recovery. The best form of treatment of late onset paraplegia is the prevention of development of severe kyphosis in initial active stage of disease.

Background: Here we present a case of cervical spinal epidural abscess causing neurologic deficits despite negative serologic tests., Case Description: Unlike a previously reported case, blood cultures and serologic tests were negative for this 50-year-old male with cervical brucellar spondylodiscitis and neurologic deficits. The diagnosis was made based on magnetic resonance imaging (MRI) findings and tissue culture. We drained the epidural abscess, performed anterior cervical discectomy fusion with an iliac strut bone graft, and administered antimicrobial therapy (gentamicin and doxycycline). At the 1-year follow-up visit, a C-spine lateral plain radiograph revealed solid fusion achieved by autogenous strut bone grafting at C4-C5 and C5-C6, and a T2-weighted image showed that epidural abscess and granulation tissue causing spinal cord compression were absent. In addition, the patient had recovered from all of the neurologic deficits with the exception of voiding difficulty., Conclusion: It is important for clinicians to consider brucellar cervical spondylodiscitis when an epidural abscess is identified in a patient with a history of potential exposure. We recommend both blood and tissue cultures for diagnosis when serologic tests are negative., (Copyright © 2012 Elsevier Inc. All rights reserved.)

We present a 28-year-old man with neck pain, fevers, elevated acute-phase reactant levels and progressive quadraparesis. He had a history of intravenous drug abuse. Contrast-enhanced cervical spine MRI revealed a heterogeneously enhancing mass in the anterior atlantoaxial region with spinal cord compression. The patient was taken emergently to the operating room for decompression. Although the transoral approach for access to the ventral atlantoaxial complex for resection of compressive inflammatory and neoplastic lesions is well described, reports of evacuation of infectious lesions via this route are limited. Thus, we report drainage of a ventral high cervical abscess via the transoral approach., (Copyright © 2012. Published by Elsevier Ltd.)

Actinomycosis is a rare, chronic, suppurative, granulomatous infection caused by a group of gram-positive anaerobic bacteria belonging to the natural flora of the oral cavity and gastrointestinal and urogenital tracts. It may involve several organs. This case study refers to pulmonary actinomycosis with chest wall involvement and cord compression in a 29-year-old male who presented with fever, cough, hemoptysis, neck pain, and paresis and plegia of the lower limbs of 5-month duration.

Neurosyphilis is recognized as a potential cause of hypertrophic pachymeningitis, but modern reports are few. A middle-aged man presented to hospital with a 1 month history of lower limb pain and weakness. Cerebrospinal fluid analysis showed pleocytosis with high protein levels and a positive venereal disease research laboratory result. Cervical spinal cord resonance imaging disclosed a dural contrast enhancement suggestive of pachymeningitis. Biopsy of the dura mater revealed a thick inflammatory process. Despite being treated accordingly, the patient rapidly deteriorated and died. The patient was diagnosed as having subacute hypertrophic cervical pachymeningitis which caused spinal cord compression. Serological evidence of neurosyphilis was present. Physicians should still be aware of this cause of hypertrophic pachymeningitis.

Spinal abscess is rare in children, especially in young infants. The most common etiology is bacteria, Staphylococcus aureus in particular. Mycobacterium tuberculosis is another cause. We report an unusual cervical spinal abscess with spinal cord compression in a 13-month-old child. The presenting symptoms were weakness in the right arm and, predominantly, the right leg for 1 month. Magnetic resonance imaging showed an abscess of the cervical spine, extension with bony destruction, and spinal cord compression. The patient underwent an emergency neurosurgical decompression and laminectomy. Pathology and culture results confirmed Mycobacterium tuberculosis. After 12 months of antituberculosis treatment, the child could walk with a walker. At 37 months, he was able to walk without assistance. We conclude that spinal tuberculosis should be considered in cases of children with spinal cord-compression symptoms and an image showing an extraspinal abscess. Early diagnosis and prompt treatment are critical for maximizing a functional recovery.

Distinguishing between an infective and malignant process provides a diagnostic challenge for clinicians. This case highlights an example of an acute spinal cord compression that could fall into either of these two categories. The diagnosis in this case of disseminated Nocardiosis is an extremely rare cause of acute spinal cord compression and to our knowledge intrinsic conus medullaris infection from Nocardia has not previously been reported in the literature. Nocardia cyriacigeorgica is an emerging strain of Nocardia species recently identified which was previously categorised as Nocardia asteroides type VI infection. The challenge of eliciting the diagnosis and the need to have an index of suspicion of Nocardia as a possible aetiology agent is shown in the report. The case shows this is especially important in evaluation of a multi-system infection in an immunosuppressed individual. The case described highlights an interesting diagnostic case with the resultant causative organism an emerging strain of Nocardia species with no previous reported cases of conus medullaris involvement., ((c) 2010. Published by Elsevier B.V. All rights reserved.)

Study Design: An observational study., Objective: We report clinical, MRI and urodynamic findings in spinal tuberculosis., Setting: Tertiary care teaching hospital., Method: Patients with spinal tuberculosis having micturition disturbances or high postvoidal residual (PVR) urine were subjected to clinical evaluation, urodynamic and spinal MRI. Urinary symptoms were scored as per the American Urological Association Symptom (AUAS) Index. The outcome was defined at 12 months into complete, partial and poor., Results: Of 30 spinal tuberculosis patients, 15 had micturition disturbance and included urinary retention in 4, stress incontinence in 2, hesitancy in 6, urgency in 11 and urge incontinence in 9 patients. Thirteen patients had paraparesis and one had quadriparesis. Spinal MRI revealed granuloma in 2, dorsal vertebral involvement in 12 and cervical and lumbar vertebral involvement in 1 patient each. On urodynamic study, detrusor hyperreflexia (DH) with high-pressure voiding was present in six, detrusor areflexia (DA) in four, normal study in one and increased PVR urine in the remaining patients. AUAS score improved on follow-up. DA changed to DH with high-pressure voiding in one patient. The 15 patients without micturition disturbance had no horizontal sensory level, milder or no weakness and only 2 had spinal cord signal changes. Patients with micturition disturbances had poorer functional recovery at 1 year compared to those without micturition disturbances., Conclusion: Bladder symptoms were present in 50% of the admitted patients with spinal tuberculosis and related to severity of paraplegia, horizontal sensory level, cord signal abnormality and poorer outcome compared to those without spinal tuberculosis. Urodynamic study helped in categorization and management.

Craniovertebral junction tuberculosis (CVJ TB) is a rare disease, potentially causing significant neurological deficits and even death. We report on a 80-year-old woman presenting with CVJ TB without pulmonary involvement. The diagnosis was made by biopsy of the cervical lymph node showing granulomatous caseation necrosis. Despite extensive erosion of the clivus, C1, and C2, and spinal cord compression, the patient was effectively managed with antituberculous drug therapy and conservative neck stabilization. Neck pain resulting from cervical spondylosis is common in elderly people. However, even if there is no obvious pulmonary involvement, CVJ TB should be considered in the differential diagnosis, especially in patients with painful neck stiffness. The most useful method available for evaluating this region is a combination of CT scan and MRI study. CVJ TB can be managed conservatively, except for a selected few cases, regardless of the extent of bony destruction.

A 68-year-old male presented with rapidly progressive paraplegia. MR images of the thoracic spine were interpreted as being consistent with an abscess within an epidural lipomatosis compressing the spinal cord. Laminectomy was performed, and a large amount of pus was drained from the epidural lipomatosis, from which Staphylococcus aureus was isolated. This is the first reported case of an abscess involving an epidural lipomatosis.

Intramedullary cysticercosis is a rare form of cysticercosis in the central nervous system. A 55-year-old woman was admitted with low back pain, urinary incontinence, paraparesis and sensory deficit. Her MRI showed a well-defined intramedullary cystic lesion at T7 vertebral level with peripheral enhancement on contrast. She underwent a T7-T8 laminectomy and excision of the lesion. Histopathology revealed the lesion to be a cysticercus granuloma. A postoperative course of albendazole was given. The patient showed significant neurological improvement at follow-up., ((c) 2009 Elsevier Ltd. All rights reserved.)

Purpose: Cervical spondylodiscitis is a quite rare finding regarding the number and the common location of spinal abscesses in the lumbar region. While in thoracic and lumbar discitis, single-step surgery with neural decompression, disc space evacuation, and subsequent fusion is well known, there is no such report in cervical discitis. Here the authors present their experience with ventral polyetherketone (PEEK) cage fusion in cervical spondylodiscitis in a single-step procedure., Methods: Between January 2006 and November 2008, five patients (three men, two woman; ages 71, 77, 58, 66 and 66 years) suffering from cervical spondylodiscitis and epidural abscess underwent disc evacuation, myelon decompression and subsequent ventral fusion using an empty PEEK cage disc replacement in one single setting. All five patients presented with significant neurological symptoms like cervicobrachialgia, tetraparesis and disturbance of the urinary incontinence. In all five patients, disc evacuation, myelon decompression and cervical fusion using a PEEK cage disc replacement in a single-stage surgery were performed. All wounds were closed primarily. Postoperatively, all patients received a specific antibiotic therapy for at least 6 weeks., Results: This treatment strategy was successful in all patients with respect to clinical signs, laboratory parameters and radiological findings. All patients improved neurologically. Follow-up revealed a stable osteosynthesis without signs of instability. One cage was explanted despite neurological improvement and normal infectious parameters at another surgical department. No complications were observed., Conclusions: In all, abscess drainage and ventral fusion with PEEK-cage disc replacement in one single setting was proven to be a successful treatment option in cervical discitis and spinal epidural abscess.

Study Design: Prospective study., Objective: To determine whether F-18 fluoro-deoxy-glucose positron emission tomography/computed tomography (F-18 FDG PET/CT) follow-up imaging after treatment in patients with spinal infection (SI) could provide useful prognostic information and determine the residual SI., Summary of Background Data: There are seldom data on the capability of follow-up imaging methods to predict residual disease and treatment efficacy in patients with SI., Methods: Thirty patients with SI underwent F-18 FDG PET/CT at initial and during follow-up. From F-18 FDG PET/CT, quantitative indexes were obtained. The residual SI was determined by the presence of preoperative symptoms, hematological infection marker, and radiologic findings., Results: The SUVmax were significantly declined after treatment in both of residual (2.85 +/- 1.17 vs. 2.06 +/- 1.03; P < 0.0001) and nonresidual SI (4.31 +/- 2.07 vs. 1.44 +/- 0.46; P < 0.0001). The SUVmean were also decreased after treatment in both of residual (1.45 +/- 0.45 vs. 1.04 +/- 0.29; P = 0.0014) and nonresidual SI (2.09 +/- 1.03 vs. 0.81 +/- 0.25; P < 0.0001). By lesion-based analysis, when < or =43.01% of %deltaSUVmax was used as threshold value, the area under curve (AUC) was 0.879 (P = 0.0001). The sensitivity and specificity were 85.7% and 82.6%, respectively. When < or =44.12% of %deltaSUVmean was used as threshold value, AUC was 0.828 (P = 0.0001). The sensitivity and specificity were 85.7% and 68%, respectively. In patient-based analysis, when < or =46.14% of %deltaSUVmax was used as threshold value, AUC was 0.904 (P = 0.0001). The sensitivity and specificity were 100% and 76.9%, respectively. When < or =41.78% of %deltaSUVmean was used as threshold value, AUC was 0.923 (P = 0.0001). The sensitivity and specificity were 100%, 76.9%, respectively., Conclusion: F-18 FDG PET/CT is useful for discrimination of residual and nonresidual SI after treatment. Among the various quantitative indexes, %deltaSUVmax is a potent predictor of residual SI in the current study.

Infection secondary to a dermal sinus most commonly occurs in the form of cutaneous, epidural, or subdural abscesses. Rarely, it can result in an intramedullary abscess as a result of a dermal sinus. This study presents a clinicoradiological profile of 19 cases harboring abscesses within the dermoids and highlights the importance of dermal sinus acting as a pathway for infections to enter the nervous system. Emergent exploration, pus drainage, and minimal abscess wall excision along with prolonged antibiotic administration remained the management of choice in all cases. Methicillin-sensitive Staphylococcus aureus was the commonest offending organism. In all, 7 patients recovered to normal neurological status, 5 showed no improvement, and 7 improved partially. Improvement in motor power was noted, albeit partially, but bladder functions failed to recover even at long-term follow-up. Even when such infective complications of dermal sinuses are rare, these are potentially serious and disabling.

Objectives: Spinal epidural abscess (SEA) is a rare disease and its early detection and appropriate treatment is essential to prevent high morbidity and mortality. There are only few single-institution series who report their experiences with the microsurgical management of SEA and treatment strategies are discussed controversially. Within the last 15 years the authors have treated 46 patients with SEA. This comparatively high number of cases encouraged us to review our experiences with SEA focussing on the clinical presentation, microsurgical management and outcome., Methods: Clinical charts of 46 cases with a spinal epidural abscess treated between 1990 and 2004 were reviewed. There were 30 men and 16 women, the age ranged between 32 and 86 years (mean: 57 years). The clinical mean follow-up was 8.5 months (range: 2-84). The clinical presentation and severity of neurological deficits were measured by the Frankel grading system on admission and on follow-up visit., Results: The abscess was located in the cervical spine in 8, the thoracic spine in 17 and the lumbar spine in 21 patients. On admission 8 patients were in Frankel grade A, 7 in B, 15 in C, 8 in D and 8 in E. During follow-up 1 patient was in Frankel grade A, 1 in B, 5 in C, 13 in D and 24 in E. 37 patients underwent primary microsurgery with abscess drainage or removal of chronic granulomatous tissue. The clinical symptoms in 4 patients worsened shortly after the operation due to a compression fracture of the vertebral body (n=2) or progress of the abscess (n=2) making re-operation necessary. 9 patients with severe critical illness or without neurological deficits had primarily a CT-guided puncture for assessment of the causative organism. 3 of them needed additional surgical therapy within the hospital stay because of a new neurological deficit. All patients were immobilised and treated with antibiotics for at least 6 weeks. The mortality was 6.5%. As for complications we noted septicaemia (n=5), meningitis (n=1) and a transient malresorptive hydrocephalus (n=1)., Conclusion: Early diagnosis, microsurgical therapy with appropriate antibiotic therapy and careful observation of patients are the keys to successful management of SEA. The goal of surgical treatment is to isolate the causative organism and to perform a decompression at the site of maximal cord compression in cases of neurological deterioration or severe pain. Instrumentation with primary fixation does not seem to be imperative. In cases of post-operative worsening, a fracture of additionally infected bony elements has to be considered and a stabilisation should be discussed on an individual basis.

Background Context: Cervical involvement due to spinal brucellosis is quite rare. Although surgery usually is not necessary in spinal brucellosis, most of the patients with cervical involvement require surgical treatment because of the high rate of neurological involvement and spinal cord compression., Purpose: To present a unique case with cervical spinal brucellosis with epidural and paravertebral abscesses and to discuss the treatment alternatives of this disease., Study Design: A case report., Methods: A 61-year-old patient with spinal cord compression syndrome due to cervical spinal brucellosis was reported. He was treated by triplet antibiotherapy for 24 weeks. On magnetic resonance imaging, spinal cord compression caused by epidural abscess and granulation tissue, and prevertebral abscess were seen., Results: At the end of the treatment, there were no complaints, neurological findings, or positive infection markers. There was not epidural compression on control magnetic resonance imaging., Conclusions: Surgery may not be required in all cervical spinal brucellosis cases with epidural compression and neurological involvement. Conservative treatment with close observation may be sufficient in these patients who are usually older people.

Objectives: To study imaging changes associated with spinal tuberculosis (ST) over time and evaluate their association with clinical and laboratory data., Methods: Between 1997 and 2004, patients with proven ST in our institution were prospectively enrolled and treated for 1 year. Clinical and laboratory data were collected at baseline and every 3 months. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed at baseline. MRI was performed at least twice during treatment and at the end of treatment., Results: Nineteen patients were enrolled; neurological signs were present at baseline in 14 patients (74%). Initial MRI/CT findings comprised (in percentages of patients) the following: paravertebral abscesses (100/100); intradiscal abscesses (47/0); and epidural abscesses (82/24) with spinal cord compression (64/18) or radicular compression (36/0). Edema of the vertebral body was observed on initial MRI in all the patients. Full follow-up data were available for 15 patients: all were cured with a mean follow-up of 25 months after the end of treatment. Weight gain was nearly maximal at 6 months, and pain relief was achieved within 9 months. C-reactive protein returned to normal after 3 months. On MRI, all epidural abscesses disappeared within 9 months; paravertebral abscesses disappeared after 3, 6, and 12 months in 45, 50, and 85% of patients, respectively. Vertebral body signal converted to a fatty signal in 75% of cases at 12 months., Conclusions: Significant imaging abnormalities can persist after successful treatment of ST. These findings suggest that MRI need not be repeated in patients with clinical and laboratory improvement.

We present a conus medullaris tuberculoma in a 12-year-old girl. She presented with low backache, weakness of both lower limbs and urinary disturbance. Magnetic resonance imaging revealed a D10-L1 intramedullary mass. The tumour was excised and the biopsy was suggestive of tuberculoma. The patient received antituberculous therapy postoperatively and improved. The relevant literature is discussed briefly.

Candida albicans vertebral osteomyelitis is rare. Three cases are presented. Without antifungal treatment, they developed spinal collapse and neurological deterioration within 3-6 months from the onset of symptoms. There was a delay of 4.5 and 7.5 months between the onset of symptoms and surgery. All patients were managed with surgical debridement and reconstruction and 12-week fluconazole treatment. The neurological deficits resolved completely. The infection has not recurred clinically or radiologically at 5-6 years follow-up. Although rare, Candida should be suspected as a causative pathogen in cases of spinal osteomyelitis. Without treatment the disease is progressive. As soon as osteomyelitis is suspected, investigations with MRI and percutaneous biopsy should be performed followed by medical therapy. This may prevent the need for surgery. However, if vertebral collapse and spinal cord compression occurs, surgical debridement, fusion and stabilisation combined with antifungal medications can successfully eradicate the infection and resolve the neurological deficits.

Study Design: Case report of a 64-year-old man with psoas abscesses, epidural abscess and spondylitis after acupuncture., Objective: To report a case of paraplegia caused by spinal infection after acupuncture., Setting: Seoul, Korea., Case Report: A 64-year-old man came to an emergency room because of severe back pain. At 3 days prior to visit, the patient received acupuncture therapy to the low back with a needle about 10 cm in length because of back pain. Pain was aggravated gradually for 3 days. Escherichia coli sepsis developed with altered mentality during admission. At hospital day 9, he regained his consciousness and was found to have paraplegia. Abdominal computerized tomography (CT) and lumbar spine magnetic resonance imaging (MRI) revealed abscesses of bilateral psoas muscles and spondylitis with epidural abscess. After conservative management with intravenous administration of antibiotics, infection was controlled but the patient remained paraplegic (ASIA scale C L1 level) without neurological recovery., Conclusion: Paraplegia might result from complications of an acupuncture therapy.

Aspergillus infection of the central nervous system (CNS) is an uncommon disease. Most of the reported cases are of sinocranial spread and cases with contiguous spread to spinal cord from lung and other organs are uncommon. A case of pulmonary aspergillosis with extension to thoracic vertebrae forming a paraspinal mass resulting in neurological deficit due to Aspergillus flavus, is reported. The 43 year old patient did not have any obvious predisposing condition. He presented with loss of motor function and succumbed to the infection despite operative intervention and antifungal therapy. A brief update on CNS aspergillosis is presented along with detailed clinical, radiological and laboratory work up of the patient.

The natural history of uncomplicated hematogenous pyogenic spondylodiscitis is self-limiting healing. However, a variable degree of bone destruction frequently occurs, predisposing the spine to painful kyphosis. Delayed treatment may result in serious neurologic complications. Early debridement of these infections by percutaneous transpedicular discectomy can accelerate the natural process of healing and prevent progression to bone destruction and epidural abscess. The purpose of this manuscript is to present our technique of percutaneous transpedicular discectomy (PTD), to revisit this minimally invasive surgical technique with stricter patient selection, and to exclude cases of extensive vertebral body destruction with kyphosis and neurocompression by epidural abscess, infected disc herniation, and foraminal stenosis. In a previously published report of 28 unselected patients with primary hematogenous pyogenic spondylodiscitis, the immediate relief of pain after PTD was 75%, and in the long-term follow-up, the success rate was 68%. Applying stricter patient selection criteria in a second series of six patients (five with primary hematogenous spondylodiscitis and one with secondary postlaminectomy-discectomy spondylodiscitis), all patients with primary hematogenous spondylodiskitis (5/5) experienced immediate relief of pain that remained sustained at 12-18 months follow-up. This procedure was not very effective, however, in the patient who suffered from postlaminectomy infection. This lack of response was attributed to postlaminectomy-discitis instability. The immediate success rate after surgery for unselected patients in this combined series of 34 patients was 76%. This technique can be impressively effective and the results sustained when applied in the early stages of uncomplicated spondylodiscitis and contraindicated in the presence of instability, kyphosis from bone destruction, and neurological deficit. The special point of this procedure is a minimally invasive technique with high diagnostic and therapeutic effectiveness.

A 69-year-old man living in Florence reported fever and acute lumbar pain one month after transurethral resection of a superficial transitional cell carcinoma of the bladder. The radionuclide bone scan suggested metastatic lesions of the L3-L4 vertebrae. However cobalt treatment was ineffective. A bone biopsy of L4 showed an inflammatory pattern and antibiotic therapy was started which did not produce any clinical improvement. Six months after the onset of the back pain brucellar spondylitis was serologically diagnosed and treatment with doxycycline and streptomycin produced a significant clinical and radiological improvement. After 2 months the patient's wife presented with fever and lumbar pain, and brucellar spondylitis was diagnosed as well. An extensive epidemiological examination revealed that 8 months earlier the family had eaten unpasteurized goat cheese and serological examination of the entire family showed that 3 out of 4 members had significant titres of brucellar antibodies. Finally it was discovered that 4 months after consuming the cheese the third infected subject experienced an episode of epidydimoorchitis for which no diagnosis and effective treatment was found. This family cluster of brucellar infection indicates that a high degree of suspicion in the diagnosis of brucellosis is necessary even in non-endemic areas, to reduce the delay in the diagnosis and treatment of the disease and to prevent the occurrence of complications that may prove difficult to treat.

Study Design: A case report., Objectives: To present and discuss some of the difficulties in the diagnosis of brucellar spondylitis., Setting: Ankara University, Ibni Sina Hospital, Turkey., Methods: We report a patient with paraplegia, misdiagnosed as having a malignancy or tuberculosis who actually suffered from brucellar spondylitis. Diagnosis was established by her history and a compatible clinical picture together with a standard tube agglutination (Wright test) titer of > or =1/160 of antibodies for brucellosis. The patient was treated with oral doxycycline, rifampicin, and ciprofloxacin combination., Results: At the end of the treatment, the blood Brucella Wright and anti-human globulin T titer levels decreased. Her lower limb weakness improved. She could walk, and climb stairs with the help of a cane. Urinary retention and fecal incontinence also resolved., Conclusion: Brucellosis is a systemic infection involving the musculoskeletal and nervous systems. Spondylitis frequently occurs in elderly patients. An early diagnosis of brucellar spondylitis can often be difficult. In endemic regions, as in the case of our country, brucellar spondylitis should always be considered in the differential diagnosis of older patients with back pain and constitutional symptoms. An early diagnosis will help to prevent the development of more severe complications such as spinal cord compression.

Infection with the fungus Cryptococcus neoformans is seen predominantly in two forms: (a) pulmonary and (b) cerebromeningeal. Skeletal cryptococcosis is uncommon. There have been only occasional case reports of thoracic vertebral cryptococcosis presenting as cord compression. A young female had cervical lymphadenopathy diagnosed as tuberculosis by fine needle aspiration cytology (FNAC) and was on antitubercular therapy (ATT) for 5 months. She developed rapidly progressive paraparesis and imaging demonstrated a destructive vertebral body lesion involving T2-3 with a paraspinal abscess producing cord compression. A costotransversectomy with excision of the diseased bone and bone grafting was done. Histopathological examination revealed cryptococcosis. The patient was put on antifungal medication, but expired 2 weeks after surgery. Radiological, magnetic resonance imaging and surgical finding of vertebral cryptococcosis can mimic tuberculosis. The definite diagnosis of cryptococcosis depends upon microscopic identification of the organism. A high index of suspicion leading to early surgical confirmation and institution of anti fungal therapy is necessary to reduce the mortality and morbidity.

Spinal epidural empyema is a very rare entity occurring with an estimated incidence of 1 per 10,000 hospital admissions. This condition has a reputation for presenting as a diagnostic challenge resulting in late diagnosis and delayed treatment. However, the cornerstones of treatment are prompt diagnosis and early treatment to prevent permanent paralysis and high mortality. We present a cluster of nine cases presenting to the neurosurgery unit over a 3-year period and discuss their relevant features in view of the most recent literature. The diagnosis of spinal epidural empyema was made with gadolinium-enhanced MRI in eight of nine cases. Staphylococcus aureus was isolated as the causative pathogen in all cases. All patients were treated with antibiotics. Eight patients had surgery for debridement and spinal decompression. One patient was treated successfully with antibiotics alone.

Nocardiosis refers to locally invasive or disseminated infection associated with Nocardia species. Most infections enter through respiratory tract and then disseminate systemically. Rarely primary nocardial infection of the skin of the back may spread to contiguous structures including vertebrae. A 30 years male presented with indolent skin lesion in the upper dorsal region of the back for one year following an accident and subsequently developed features of spinal cord compression and parenchymal involvement of lung. The rarity of such type of spread in an immuno-competent individual has been highlighted.

It is a retrospective study, reviewing all cases of vertebral tuberculosis recorded between 1989 and 1999 in La Rabta Hospital (Tunis). 29 patients have been included whose average age was 49 years. The main symptoms which appeared within a average period of six months were vertebral pain, associated with fever in half of the cases. The diagnosis of infectious spondylitis was made according to the results of Computer tomography in 26 cases. The diagnosis of infection was confirmed by characteristic histological pattern and/or culture biopsy. 27 patients were cured without complications except for 2 of them who developed a spinal cord compression. This complication was quickly stemmed by steroid therapy.

Spinal epidural abscess is uncommon in neonates and infants, and is usually related to previous lumbar puncture or epidural anaesthesia. Diagnosis is often delayed because of the non-specific presentation. We present a 7-week-old girl who developed paraplegia 3 weeks after transient fever and a self-limiting skin rash. MR imaging revealed an epidural contrast-enhancing lesion compressing the spinal cord. At operation, an organised granulated abscess was identified with Staphylococcus aureus the causative organism. Laminectomy and removal of the organised abscess and systemic intravenous antibiotics resulted in complete neurological recovery. The patient did not develop late spinal deformity following the decompressive laminectomy. The rapid onset of paraplegia can often be missed in such a young child but should be promptly investigated, as surgical treatment of cord compression carries an excellent prognosis for neurological recovery. We review the literature on the initial presentation, usual investigations, causative organisms and surgical management of paediatric spinal epidural abscesses.

The authors report an unusual case of spinal tuberculosis involving the posterior arch of T12 without disk lesion in a 20-year-old woman presenting with posterior compression of the spinal cord. The diagnosis was suggested at CT and MR imaging and confirmed by histological study after surgical resection. CT provides good evaluation of the bony lesion and may suggest intraspinal extension. MRI is superior for evaluation of cord compression. The patient improved after surgical and medical treatment. The imaging features of this entity are reviewed.

Study Design: A case report of Mycobacterium xenopi., Objectives: To present a case report of a vertebral osteomyelitis caused by M. xenopi and to review the world literature on the subject., Summary of Background Data: M. xenopi is most commonly a pulmonary pathogen in immunosuppressed patients or those with underlying lung disease. Infection of the spine is very rare, with only four cases reported. Three of these cases occurred in immunosuppressed patients, and the fourth in a patient with previous tuberculosis osteomyelitis of the spine., Methods: The information was obtained from a review of the patient's clinical notes and follow-up appointments., Results: The patient was a 73-year-old woman with an M. xenopi osteomyelitis of T6-T7, confirmed by magnetic resonance imaging and a computed tomography-guided biopsy. She was treated with surgical decompression and stabilization before a 2-year antibiotic regimen was begun. At follow-up assessment 1 year after the antibiotics were finished, she still had some ongoing back pain, but no evidence of relapse., Conclusions: This is the first reported case of an M. xenopi infection of the spine in a patient with no predisposing factors. This type of infection can be difficult to treat, with a high relapse rate reported despite prolonged courses of antibiotics.

A retrospective survey of 36 cases treated in the Department of Neurosurgery, Hacettepe University Hospitals since 1970 was performed. Clinical presentation, aetiology and outcome of this rare disease compared to recently published series. All cases were admitted with signs of neural compression. Clinical and laboratory data suggesting an infectious origin were present only in 4 cases. Radiological investigation including magnetic resonance imaging in 10 patients, were not confirmative for an epidural abscess except for two cases. All cases underwent urgent surgical decompression and tuberculous abscess either in granulation or pus form was found in the majority. Overall mortality rate was 5.8%. Outcome was closely related to the neurological condition on admission rather than the underlying infectious origin. When compared with recently reported series, our cases demonstrated a significant divergence in terms of clinical presentation, pathogenesis and outcome. The most probable reason for this discrepancy is that risk factors for compromised immunity or systemic infection were much less than the other series and mycobacterium tuberculosis is the responsible agent in the majority which has a much more favourable outcome than non-spesific infections.

Eight patients presented neurological signs secondary to Brucella infection. The clinical presentation was a meningoencephalitis in three cases, a meningoencephalomyelitis in one case, an epiduritis with spinal cord compression in one case, an acute polyradiculoneuritis in two cases and a chronic polyradiculoneuritis in one case. Acoustic nerve was impaired in seven cases. Cerebrospinal fluid (CSF) analysis revealed a lymphocytic meningitis and a high protein concentration in all cases. The agglutination test titers were elevated in the serum and in the CSF of seven patients (> or = 1/80) and two patients respectively. Brucella melitensis culture was disclosed in the blood of one patient and in the CSF of two patients. Three patients were treated by the association cycline and rifampicin whereas a tritherapy including cycline, rifampicin and TMP-SMZ was used in the other cases. Outcome was favorable in seven cases. This study outlines the polymorphism of neurological manifestations due to brucellosis, even in familial cases and this diagnostic must be especially done in Middle East and South Mediterranean countries.

Spinal tuberculosis is the first etiology of spinal cord compression in our areas. We are studying the epidemiological, clinical and therapeutic aspects of Pott's disease. We have collected all children aged from 0 to 15 years admitted for Pott's disease in department of Neurology in CHU Fann SenegaIL from January 1st 1983 to December 31st 1997 spinal tuberculosis. The diagnosis was both clinical and paraclinical. 27 children aged to 2-15 years were hospitalized for Pott's disease. The sex-ratio was equal to 2 in favour of boys. 77.77% of patients were consulted more than a month after the outbreak of the paraplegia. The notion of tuberculous contagion was found in 25.92% of the cases. The main clinical signs were paralysis of the limbs, sensory symptoms and bladder sphincter dysfunction. In 96.29% anomaly of disc and vertebra were recorded, more often affecting two vertebrae. The myelography, performed in 13 patients objectivized an epidural stop in 92.30% of the cases. There was a favorable evolution in 92% of patients under antituberculous chemotherapy. Spinal tuberculosis is an affection cheating all ages and it remains the first etiology of spinal cord compression in our areas. Therefore there is a necessity of primary safety by fighting against tuberculosis what is still in our areas.