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Cervical spine fixation: a rare complication
Proceedings of the BASS 2015 Bath Meeting / The Spine Journal 15 (2015) 50S–85S CONFLICTS OF INTEREST: None. FUNDING SOURCES: None. http://dx.doi.org/10.1016/j.spinee.2014.12.100
Metastatic spinal deposits or bovine tuberculosis infection? Tom Marjoram, Saajid Kaleel; Ipswich Spinal Unit, Ipswich Hospital, Heath Road, Ipswich, Suffolk IP45PD BACKGROUND CONTEXT: Non-invasive bladder tumours have been treated with resection followed by intravesical Bacillus Calmette-Guerin (BCG) instillation since 1976. It is believed to exert its anti-tumour activity via local modulation of immune responses, which results in inflammation and subsequent elimination of malignant cells. Orthopaedic complications of this therapy are uncommon and include myco-bacterial osteomyelitis and reactive arthritis. There have been 5 previous published cases of spinal disc infection following BCG treatment making it a very rare complication. STUDY DESIGN/SETTING: Case Report. PATIENT SAMPLE: Single Case. METHODS: This case describes a 77 year old gentleman presenting to the spinal services with 10 months of back pain. 1 year previous to this onset he had undergone 3 intravesical Bacillus Calmette-Guerin (BCG) therapy for a bladder tumour following a transurethral resection. An MRI was arranged which showed Lesions at L1 involving the L1/2 disc, T12 involving the T11/12 disc and the T8/9 disc initially thought to represent multiple metastases. After discussion at the Multidisciplinary team meeting was thought to represent either multi-level infection or multiple level metastatic disease. RESULTS: A right transpedicular L1/2 biopsy was undertaken and samples sent for histological analysis. The samples taken did not show any evidence of malignancy but did show the presence of acid fast bacilli (mycobacteria) subsequent culture of the samples confirmed these to be BCG sensitive to Rifampicin, Isonaizid, Ethambutol but resistant to Pyrazinamide. The patient was therefore given a diagnosis of ‘BCG discitis’ was made and treatment with Rifinah (rifampicin and isoniazid) Ethambutol and Pyridoxine started. The patient has had significant improvement in symptoms with this therapy. CONCLUSIONS: Spinal complications of intravesical BCG therapy are rare. Metastatic diseases spreading to the spine are much more common and the initial assumption after the multilevel pathology was that this represented metastatic disease. This case is important in highlighting that while rare BCG infection should be considered in patients who have spinal pathology after intravesical BCG therapy. Previous cases have assumed haematogenous spread. Interestingly, during the therapy course this patient’s treatment had to be stopped due to prostatic symptoms after failed catheterisation for which he underwent a transurethral resection of the prostate, biopsy taken at this time showed a benign prostatic disease but also the presence of mycobacterium. Giving us a clear pathway for the haematogenous spread to the spinal circulation, the traumatic difficult catheterization allowed the inoculation of the prostate with the BCG mycobacterium which is supported by its presence in the biopsy tissue. The circulation of the prostate is well known to anastamose with the spinal circulation providing a route for haematogenous spread. In Summery this interesting and rare case Highlights the need to include iatrogenic mycobacterial infection as a differential for spinal metastases in this group of patients and also clarifies and supports a method of haematogenous spread. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None. http://dx.doi.org/10.1016/j.spinee.2014.12.101
73S
Cervical spine fixation: a rare complication Nicholas Leaver, Alexandra Colby, Nathan Appleton, Dale Vimalachandran; University of Liverpool 19 Hacking Drive, Longridge PR3 3EP BACKGROUND CONTEXT: Anterior spine plating is now a routine procedure for fixing unstable vertebral fractures, caused by trauma. Current plating methods are safe and very effective in allowing bony fusion to occur. Screw migration after several years is a very rare and potentially fatal complication. PURPOSE: We report a case of screw displacement 16 months following anterior cervical spine plating. We aim to educate that instrumental failure is possible following spinal surgery. STUDY DESIGN/SETTING: Case Report. METHODS: A 57 year old man presented in November 2012 after falling. This led to a fracture of C5-C7, which were subsequently repaired by two operations, he did, however, suffer tetraplegia. He was referred later, by his GP for microcytic anaemia with unknown cause. There were no red flag symptoms; however he was referred for an OGD and colonoscopy to rule out any gastrointestinal pathology. RESULTS: The OGD reported an obstruction just distal to the cricopharyngeus of food and a suspicious metallic object. His X-ray and CT scan of the cervical spine showed that the anterior plate and screw fixation at C6 & C7 level, were displaced, and this caused one of the screws to perforate the oesophagus and hence it was visualised at endoscopy. It was decided that surgery wasn’t immediately necessary for our patient and he is currently being managed conservatively. CONCLUSIONS: This case emphasises that long term follow up is required for all patients following anterior fixation of the cervical spine and highlights that, although rare, screw migration is a possible risk of cervical spine surgery in the years following. Early medical or surgical intervention is key and associated with a better outcome. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None. http://dx.doi.org/10.1016/j.spinee.2014.12.102
Patient Reported Outcome Measures (PROMS) in patients undergoing anterior cervical discectomy and fusion (ACDF) for brachalgia Tim Pigott, Kate McCrystal; Walton Centre Foundation Trust BACKGROUND CONTEXT: ACDF is a gold standard procedure for the relief of arm pain. PURPOSE: To assess PROMS in a longitudinal cohort of patients undergoing ACDF. STUDY DESIGN/SETTING: Prospective longitudinal cohort of patients using Spine Tango registry. PATIENT SAMPLE: All applicable patients from March 2011 to October 2013. OUTCOME MEASURES: Core Outcome Measures Index (COMI) pre and post operatively to 12 months. METHODS: All patients undergoing ACDF at a single institution were consented and enrolled into the Spine Tango Registry. COMI forms were administered pre-operatively, at 3 months, and at 12 months post-operatively. Non-responders were reminded by mail and subsequently contacted by phone. RESULTS: 538 patients were enrolled. 80% of patients completed a preop COMI, 71% at 3 months and 51% at 12 months. VAS neck was 6.2 preoperatively, 4.2 at 3 months, and 3.8 at 12 months. VAS arm pain was 6.9 pre-operatively, 4.2 at 3 months, and 3.9 at 12 months. The mean COMI score was 7.5 pre-operatively, 5.2 at 3 months and 4.4 at 12 months. 90% of patients were satisfied with their medical care, and over 90% of patients describe their operation as helping. The recorded surgical complication rate was 3.9%. The patient reported complication rate at 3 months was 22%, and
Metastatic spinal deposits or bovine tuberculosis infection? Tom Marjoram, Saajid Kaleel; Ipswich Spinal Unit, Ipswich Hospital, Heath Road, Ipswich, Suffolk IP45PD BACKGROUND CONTEXT: Non-invasive bladder tumours have been treated with resection followed by intravesical Bacillus Calmette-Guerin (BCG) instillation since 1976. It is believed to exert its anti-tumour activity via local modulation of immune responses, which results in inflammation and subsequent elimination of malignant cells. Orthopaedic complications of this therapy are uncommon and include myco-bacterial osteomyelitis and reactive arthritis. There have been 5 previous published cases of spinal disc infection following BCG treatment making it a very rare complication. STUDY DESIGN/SETTING: Case Report. PATIENT SAMPLE: Single Case. METHODS: This case describes a 77 year old gentleman presenting to the spinal services with 10 months of back pain. 1 year previous to this onset he had undergone 3 intravesical Bacillus Calmette-Guerin (BCG) therapy for a bladder tumour following a transurethral resection. An MRI was arranged which showed Lesions at L1 involving the L1/2 disc, T12 involving the T11/12 disc and the T8/9 disc initially thought to represent multiple metastases. After discussion at the Multidisciplinary team meeting was thought to represent either multi-level infection or multiple level metastatic disease. RESULTS: A right transpedicular L1/2 biopsy was undertaken and samples sent for histological analysis. The samples taken did not show any evidence of malignancy but did show the presence of acid fast bacilli (mycobacteria) subsequent culture of the samples confirmed these to be BCG sensitive to Rifampicin, Isonaizid, Ethambutol but resistant to Pyrazinamide. The patient was therefore given a diagnosis of ‘BCG discitis’ was made and treatment with Rifinah (rifampicin and isoniazid) Ethambutol and Pyridoxine started. The patient has had significant improvement in symptoms with this therapy. CONCLUSIONS: Spinal complications of intravesical BCG therapy are rare. Metastatic diseases spreading to the spine are much more common and the initial assumption after the multilevel pathology was that this represented metastatic disease. This case is important in highlighting that while rare BCG infection should be considered in patients who have spinal pathology after intravesical BCG therapy. Previous cases have assumed haematogenous spread. Interestingly, during the therapy course this patient’s treatment had to be stopped due to prostatic symptoms after failed catheterisation for which he underwent a transurethral resection of the prostate, biopsy taken at this time showed a benign prostatic disease but also the presence of mycobacterium. Giving us a clear pathway for the haematogenous spread to the spinal circulation, the traumatic difficult catheterization allowed the inoculation of the prostate with the BCG mycobacterium which is supported by its presence in the biopsy tissue. The circulation of the prostate is well known to anastamose with the spinal circulation providing a route for haematogenous spread. In Summery this interesting and rare case Highlights the need to include iatrogenic mycobacterial infection as a differential for spinal metastases in this group of patients and also clarifies and supports a method of haematogenous spread. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None. http://dx.doi.org/10.1016/j.spinee.2014.12.101
73S
Cervical spine fixation: a rare complication Nicholas Leaver, Alexandra Colby, Nathan Appleton, Dale Vimalachandran; University of Liverpool 19 Hacking Drive, Longridge PR3 3EP BACKGROUND CONTEXT: Anterior spine plating is now a routine procedure for fixing unstable vertebral fractures, caused by trauma. Current plating methods are safe and very effective in allowing bony fusion to occur. Screw migration after several years is a very rare and potentially fatal complication. PURPOSE: We report a case of screw displacement 16 months following anterior cervical spine plating. We aim to educate that instrumental failure is possible following spinal surgery. STUDY DESIGN/SETTING: Case Report. METHODS: A 57 year old man presented in November 2012 after falling. This led to a fracture of C5-C7, which were subsequently repaired by two operations, he did, however, suffer tetraplegia. He was referred later, by his GP for microcytic anaemia with unknown cause. There were no red flag symptoms; however he was referred for an OGD and colonoscopy to rule out any gastrointestinal pathology. RESULTS: The OGD reported an obstruction just distal to the cricopharyngeus of food and a suspicious metallic object. His X-ray and CT scan of the cervical spine showed that the anterior plate and screw fixation at C6 & C7 level, were displaced, and this caused one of the screws to perforate the oesophagus and hence it was visualised at endoscopy. It was decided that surgery wasn’t immediately necessary for our patient and he is currently being managed conservatively. CONCLUSIONS: This case emphasises that long term follow up is required for all patients following anterior fixation of the cervical spine and highlights that, although rare, screw migration is a possible risk of cervical spine surgery in the years following. Early medical or surgical intervention is key and associated with a better outcome. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None. http://dx.doi.org/10.1016/j.spinee.2014.12.102
Patient Reported Outcome Measures (PROMS) in patients undergoing anterior cervical discectomy and fusion (ACDF) for brachalgia Tim Pigott, Kate McCrystal; Walton Centre Foundation Trust BACKGROUND CONTEXT: ACDF is a gold standard procedure for the relief of arm pain. PURPOSE: To assess PROMS in a longitudinal cohort of patients undergoing ACDF. STUDY DESIGN/SETTING: Prospective longitudinal cohort of patients using Spine Tango registry. PATIENT SAMPLE: All applicable patients from March 2011 to October 2013. OUTCOME MEASURES: Core Outcome Measures Index (COMI) pre and post operatively to 12 months. METHODS: All patients undergoing ACDF at a single institution were consented and enrolled into the Spine Tango Registry. COMI forms were administered pre-operatively, at 3 months, and at 12 months post-operatively. Non-responders were reminded by mail and subsequently contacted by phone. RESULTS: 538 patients were enrolled. 80% of patients completed a preop COMI, 71% at 3 months and 51% at 12 months. VAS neck was 6.2 preoperatively, 4.2 at 3 months, and 3.8 at 12 months. VAS arm pain was 6.9 pre-operatively, 4.2 at 3 months, and 3.9 at 12 months. The mean COMI score was 7.5 pre-operatively, 5.2 at 3 months and 4.4 at 12 months. 90% of patients were satisfied with their medical care, and over 90% of patients describe their operation as helping. The recorded surgical complication rate was 3.9%. The patient reported complication rate at 3 months was 22%, and