European Spine Journal

The aim of this study was to present a unique case of intramedullary brucellar granuloma (IBG) and to discuss the diagnosis and management. To our knowledge, only one case of thoracic IBG has been reported previously, and our case is the first in cervical spine. A 35-year-old female patient was admitted with headache, pain and weakness in her four extremities. She had no gastrointestinal symptoms and fever. She had been diagnosed with Brucella meningitis 3 months ago and a triple therapy of doxycyclin, rifampicin and trimetoprim/sulfametoxazol (TMP/SMZ) had been started. Medical history revealed that she had ingested raw cheese and taken her medication improperly. Loss of strength was detected in her four extremities, which led us to assume the formation of a mass lesion at cervical level. Therefore, we performed a magnetic resonance imaging scan and found enhancement of an intramedullary mass lesion at cervical 1–2 level. Diagnosis of neurobrucellosis was confirmed by titer of >1/160 Brucella antibodies both in blood and cerebrospinal fluid. Based on these findings, brucellar granuloma of cervical spine was diagnosed and a combination therapy of doxycyclin, TMP/SMZ and rifampicin was administered for additional 6 months. At the ninth month of treatment, the patient recovered both radiologically and clinically. Our case is unique, in terms of cervical IBG formation. The excellent response to antimicrobial therapy in our patient suggests that, a trial of medical treatment for 6 months may be effective in such cases.

This study evaluated whether addition of a cervical spine locking plate (CSLP) in two-level disc fusions improved the postoperative stability and reduced the time to healing. Radiostereometric analysis was used to obtain precise recordings of the three-dimensional motion between the fused vertebrae. Eighteen consecutive patients were operated on with excision of two adjacent cervical discs and anterior horseshoe grafting with autologous bone (Smith Robinson technique). Nine patients were randomized to stabilization with autologous bone grafting and CSLP plate fixation and nine patients to grafting without fixation. Clinical symptoms in terms of pain in the neck and the arm were analysed preoperatively and after 1 year using a visual analogue scale (VAS). The patients operated without a plate displayed increased rotations around the transverse axis, corresponding to the development of a kyphosis [mean value no plate/plate 14.4°/0.8° (repeated measure ANOVA: P < 0.01)]. The mean compression was 3.2 mm larger in patients operated without a plate (repeated measure ANOVA: P < 0.01). Patients operated without a plate had more arm pain at the 1-year follow up (P < 0.05, Mann-Whitney U test). The VAS score for neck pain did not differ significantly between the two groups. Plate fixation could not be demonstrated to increase the healing rate, promote more rapid fusion or influence the frequency of graft complications.

The aim of the second part of the study was to investigate the influence of parameters that lead to increased facet joint contact or capsule tensile forces (disc height, lordosis, and sagittal misalignment) on the clinical outcome after total disc replacement (TDR) at the lumbosacral junction. A total of 40 patients of a prospective cohort study who received TDR because of degenerative disc disease or osteochondrosis L5/S1 were invited to an additional follow-up for clinical (ODI and VAS for overall, back, and leg pain) and radiographic analysis (a change in disc height, lordosis, or sagittal vertebral misalignment compared with the preoperative state). Based on the final ODI, patients were retrospectively distributed into groups N (normal: <25 %) or F (failure ≥25 %) for radiographic parameter comparison. A correlation analysis was performed between the clinical and radiological results. A total of 34 patients were available at a mean follow-up of 59.5 months. Both groups (N = 24; F = 10 patients) presented a significant improvement in overall pain, back pain, and ODI over time. At the final follow-up, higher clinical scores correlated with a larger disc height, increased lordosis, and posterior translation of the superior vertebra, which was also reflected by significant differences in these parameters in the group comparison. Parameters associated with increased facet joint capsule tensile forces lead to an inferior clinical outcome at mid-term follow-up. When performing TDR, we therefore suggest avoiding iatrogenic posterior translation and overdistraction (and consecutive lordosis).

No reference material exists on the scope of long-term problems in novel spinal pain opioid users. In this study, we evaluate the prevalence and long-term use of prescribed opioids in patients of the Spinal Pain Opioid Cohort. The setting was an outpatient healthcare entity (Spine Center). Prospective variables include demographics, clinical data collected in SpineData, and The Danish National Prescription Registry. Patients with a new spinal pain episode lasting for more than two months, aged between 18 and 65 years, who had their first outpatient visit. Based on the prescription of opioids from 4 years before the first spine center visit to 5 years after, six or more opioid prescriptions in a single 1-year interval fulfilled the main outcome criteria Long-Term Opioid Therapy (LTOT). Overall, of 8356 patients included in the cohort, 4409 (53%) had one or more opioid prescriptions in the registered nine years period. Of opioid users, 2261 (27%) were NaiveStarters receiving their first opioid prescription after a new acute pain episode; 2148(26%) PreStarters had previously received opioids. The prevalence of LTOT in PreStarters/NaiveStarters was 17.2%/11.2% in their first outpatient year. Similar differences between groups were seen in all follow-up intervals. In the last follow-up year, LTOT prevalence in Prestarters/NaiveStarters was 12.5%/7.0%. Previous opioid treatment—i.e., before a new acute spinal pain episode and referral to a Spine Center—doubled the risk of LTOT 5 years later. The results underscore clinicians' obligation to carefully and individually weigh the benefits against the risks of prescribing opioid therapy. Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

A retrospective review This study was designed to compare postoperative changes in neural foramen between transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF). A retrospective analysis of 67 patients was compared to the change of neural foraminal morphometry of the two techniques. 33 patients (40 levels) had TLIF and 34 patients (39 levels) had PLIF. The two groups had similar demographic profiles. Radiological parameters including anterior and posterior disc height, foraminal height (FH), and segmental Cobb angle (SCA) were measured by sagittally reconstructed computed tomography images before and after surgery. Cage position was designated as contralateral, middle, and ipsilateral in the TLIF group. Surgical results were assessed by Odom criteria, visual analog scale (VAS), and Oswestry disability index (ODI) scores. The TLIF and PLIF group showed no bilateral difference in FH. The TLIF group had increased contralateral SCA compared to the ipsilateral side postoperatively. FH differed according to cage position in the TLIF group. When a cage was inserted deeply into the contralateral side, contralateral FH increased significantly. However, when a cage was inserted into the ipsilateral side, contralateral FH decreased significantly. Back pain was significantly lower in the TLIF group at 1 and 6 months than in the PLIF group. However, ODI and Odom scale scores were not different between the groups. TLIF may induce uneven changes in foraminal morphometry. Cage position may be the major determinant of this result.

To compare the safety and effectiveness of minimally invasive sacroiliac joint fusion (SIJF) using triangular titanium implants vs conservative management (CM) in patients with chronic sacroiliac joint (SIJ) pain. 103 adults with chronic SIJ pain at nine sites in four European countries were randomly assigned to and underwent either minimally invasive SIJF using triangular titanium implants (N = 52) or CM (N = 51). CM was performed according to the European guidelines for the diagnosis and management of pelvic girdle pain and consisted of optimization of medical therapy, individualized physical therapy (PT) and adequate information and reassurance as part of a multifactorial treatment. The primary outcome was the difference in change in self-rated low back pain (LBP) at 6 months. Additional endpoints included quality of life using EQ-5D-3L, disability using Oswestry Disability Index (ODI), SIJ function using active straight leg raise (ASLR) test and adverse events. NCT01741025. At 6 months, mean LBP improved by 43.3 points in the SIJF group and 5.7 points in the CM group (difference of 38.1 points, p < 0.0001). Mean ODI improved by 26 points in the SIJF group and 6 points in the CM group (p < 0.0001). ASLR, EQ-5D-3L, walking distance and satisfaction were statistically superior in the SIJF group. The frequency of adverse events did not differ between groups. One case of postoperative nerve impingement occurred in the surgical group. In patients with chronic SIJ pain, minimally invasive SIJF using triangular titanium implants was safe and more effective than CM in relieving pain, reducing disability, improving patient function and quality of life.

It is relatively common for a scoliosis deformity to be associated with a lumbar spondylolisthesis in adolescents (up to 48 % of spondylolistheses). In the literature two types of curve have been described: ‘sciatic’ or ‘olisthetic’. However, there is no consensus in the literature on how best to treat these deformities. Some authors advocate a single surgical intervention, where both deformities are corrected; whereas, others advocate treating them as separate entities. In this situation, it has been shown that the scoliosis will correct with treatment of the spondylolisthesis. We present a 12-year-old girl who had a concomitant high-grade spondylolisthesis and scoliosis. Her main complaints were those of low back pain and an L5 radiculopathy. We took the decision to treat the spondylolisthesis surgically, but observe the scoliosis, rather than correcting them both surgically at the same sitting. Although the immediately post-operative radiographs showed persistence of the scoliosis, 1-year follow-up demonstrated full resolution of the deformity. This young lady also had relief of her low back pain and leg pain following the surgery. There are no standard guidelines and therefore, we discuss the management of this difficult problem, exemplifying a case of a young girl who had high-grade spondylolisthesis along with a clinically non-flexible scoliosis treated at our institution. We demonstrate that it is safe to observe the scoliosis, even in high-grade spondylolistheses.