Thoracic spine infection caused by Pseudomonas fluorescens:A case report and review of literature

BACKGROUND The clinical incidence of spinal infection is gradually increasing,and its onset is insidious,easily leading to missed diagnosis and misdiagnosis,which may lead to serious complications such as nervous system dysfunction,spinal instability and/or deformity,and cause a huge burden on society and families.Early identification of the causative agent and precision medicine will greatly reduce the suffering of patients.At present,the main pathogenic bacteria that cause spinal infection are Staphylococcus aureus,Streptococcus,Pneumococcus,Escherichia coli,and Klebsiella.There are no reports of spinal infection caused by Pseudomonas fluorescens.CASE SUMMARY We report a 32-year-old female patient with spinal infection.She presented with flank pain,initially thought to be bone metastases or bone tuberculosis,and had a family background of tumors.Her clinical features and changes in imaging and laboratory tests led to the suspicion of thoracic spine infection.Histopathology of the lesion showed inflammation,tissue culture of the lesion was negative several times,and the possible pathogen-Pseudomonas fluorescens was found after gene sequencing of the lesion.The patient recovered completely after a full course of antibiotic treatment.CONCLUSION This report increases the range of pathogens involved in spinal infections,highlights the unique advantages of gene sequencing technology in difficult-todiagnose diseases,and validates conservative treatment with a full course of antibiotics for spinal infections without complications.

A novel entry point for pedicle screw placement in the thoracic spine

This study was aimed to introduce a novel entry point for pedicle screw fixation in the thoracic spine and compare it with the traditional entry point. A novel entry point was found with the aim of improving accuracy, safety and stability of pedicle screw technique based on anatomical structures of the spine. A total of 76 pieces of normal thoracic CT images at the transverse plane and the thoracic pedicle anatomy of 6 cadaveric specimens were recruited.Transverse pedicle angle（TPA）, screw length, screw placement accuracy rate and axial pullout strength of the two different entry point groups were compared. There were significant differences in the TPA, screw length, and the screw placement accuracy rate between the two groups（P〈0.05）. The maximum axial pullout strength of the novel entry point group was slightly larger than that of the traditional group. However, the difference was not significant（P 〉 0.05）. The novel entry point significantly improved the accuracy, stability and safety of pedicle screw placement.With reference to the advantages above, the new entry point can be used for spinal internal fixations in the thoracic spine.

THORACIC SPINE FRACTURES

Objective. To investigate the unique characteristics and treatment of thoracic spine fractures. Methods. Seventy seven patients with thoracic spine fractures were retrospectively reviewed. Of these, there were 37 compression fractures, 34 fracture dislocations, 3 burst fractures and 3 burst dislocations. Twenty six patients had a complete lesion of the spinal cord, 14 sustained a neurologically incomplete injury, and 37 were neurologically intact. Fifty three patients were treated nonoperatively and 24 treated operatively. Results. All patients were followed up for 2～15 years. None of the 26 patients with a complete lesion recovered any significant function. Of 37 neurologically intact patients, 13 had local pain although all of them remained normal function. Two of 14 patients with incomplete paraplegia returned to normal, 7 recovered some function and 5 did not recovered. Conclusions. Because of the unique anatomy and biomechanics of the thoracic spine, the classification commonly applied to thoracolumbar fractures is not suitable for thoracic fractures. Fusion and instrumentation are indicated when the fractures are unstable, while patients with incomplete lesion of the spinal cord may be the candidates for supplemented decompression.

Empirical study of transpedicular screw placement assisted by digital navigation templates in the thoracic spines

Objective To investigate the accuracy and feasibility of transpedicular screw placement assisted by the navigation templates in cadaveric thoracic spines.Methods Twenty thoracic cadavers specimens were randomly divided into two

Thoracic giant cell tumor after two total en bloc spondylectomies including one emergency surgery:A case report

BACKGROUND For patients with acute paraplegia caused by spinal giant cell tumor(GCT)who require emergency decompressive surgery,there is still a lack of relevant reports on surgical options.This study is the first to present the case of an acute paraplegic patient with a thoracic spinal GCT who underwent an emergency total en bloc spondylectomy(TES).Despite tumor recurrence,three-level TES was repeated after denosumab therapy.CASE SUMMARY A 27-year-old female patient who underwent single-level TES in an emergency presented with sudden severe back pain and acute paraplegia due to a thoracic spinal tumor.After emergency TES,the patient's spinal cord function recovered,and permanent paralysis was avoided.The postoperative histopathological examination revealed that the excised neoplasm was a rare GCT.Unfortunately,the tumor recurred 9 months after the first surgery.After 12 months of denosumab therapy,the tumor size was reduced,and tumor calcification.To prevent recurrent tumor progression and provide a possible cure,a three-level TES was performed again.The patient returned to an active lifestyle 1 month after the second surgery,and no recurrence of GCT was found at the last follow-up.CONCLUSION This patient with acute paraplegia underwent TES twice,including once in an emergency,and achieved good therapeutic results.TES in emergency surgery is feasible and safe when conditions permit;however,it may increase the risk of tumor recurrence.

Mechanisms of mid-thoracic spine fracture/dislocation due to falls during horse racing:A report of two cases

We reported two cases of jockeys who sustained fracture/dislocation of the mid-thoracic spine due to traumatic falls during horse racing.We examined the injury mechanism based upon the patients’diagnostic images and video footage of races,in which the accidents occurred.Admission imaging of patient 1(a 42 years old male)revealed T5 burst fracture with bony retropulsion of 7 mm causing complete paralysis below T5/6.There existed 22°focal kyphosis at T5/6,anterolisthesis of T5 relative to T6,T5/6 disc herniation,cord edema and epidural hemorrhage from T4 through T6,and cord injury from C3 through C6.Admission imaging of patient 2(a 23 years old male)revealed T4/5 fracture/dislocation causing incomplete paralysis below spinal level.There existed compression fractures at T5,T6,and T7;4 mm anterior subluxation of T4 on T5;diffuse cord swelling from T3 through T5;comminuted fracture of the C1 right lateral mass;right frontal traumatic subarachnoid hemorrhage;and extensive diffuse axonal injury.The injuries were caused by high energy flexion-compression of the mid-thoracic spine with a flexed posture upon impact.Our results suggest that substantially greater cord compression occurred transiently during trauma as compared to that documented from admission imaging.Video footage of the accidents indicated that the spine buckled and failed due to abrupt pocketing and deceleration of the head,neck and shoulders upon impact with the ground combined with continued forward and downward momentum of the torso and lower extremities.While a similar mechanism is well known to cause fracture/dislocation of the cervical spine,it is less common and less understood for mid-thoracic spine injuries.Our study provides insight into the etiology of fracture/dislocation patterns of the mid-thoracic spine due to falls during horse racing.

Is T1-2 Disc Herniation Rare? A Case Report

Backround: The English literature contains very few reports on disc herniation at upper thoracic levels. This report presents a patient with T1-2 disc herniation who underwent successful surgery. Case Presentation: A 47-year-old female presented that the right T1 root was compressed by foraminal disc herniation at the T1-2 level. Conclusion: The anterior approach is an easy and appropriate method to treat central and foraminal disc herniation of the thoracic spine.

Recurrent perimedullary arteriovenous fistula at thoracic level

Perimedullary arteriovenous fistula （PMAVF, type Ⅳ spinal cord arteriovenous malformation,SCAVM） is a direct arteriovenous shunt without abnormal vascular connection between the feeding artery and draining vein. Most patients with PMAVF present with a progressive myelopathy caused by venous hypertension, resulting in disabling deficits and incurable complete transverse myelopathy. The lesion is usually located on the surface of the spinal cord or under the pia mater at the level of the conus medullaris or cauda equina, thoracic PMAVF is rarely encountered. Most PMAVFs are fed by the anterior spinal artery （ASA）, posterior spinal artery （PSA）, or both Multiple arterial feeders from the ASA can make the treatment of the disease difficult From August 2004 to February 2005, we treated a patient with a recurrent PMAVF （type Ⅳb） at the thoracic level with multiple blood supply.

Circumspinal decompression through a single posterior incision to treat thoracolumbar disc herniation

Various surgical approaches have been successfully used in the treatment of thoracolumbar disc herniation （TLDH）. Although the anterior transthoracic approach has a reputation for better visualization than the posterolateral and lateral approaches, it involves the manipulation of the thoracic and pulmonary structures. Thus, this approach is technically demanding and prone to compromising the respiratory system. An ideal approach would involve adequate visualization and be accomplished through the posterior midline approach that is familiar to spine surgeons. The objective of this retrospective preliminary clinical study was to introduce a new surgical procedure, circumspinal decompression through a single posterior incision, for the treatment of TLDH （T10/11-L1/2） and to evaluate the surgical outcome of this procedure by comparing it to the conventional anterior transthoracic approach. Methods In this study, 15 patients （10 males, 5 females; mean age 51 years） with symptomatic TLDH underwent the circumspinal decompression through a single posterior incision procedure between January 2008 and December 2009. Altogether, 17 herniated discs were excised, with 2 discs at T10/11, 4 discs at Tll/12, 5 discs at T12/L1 and 6 discs at L1/2. Of these patients, 13 were followed up with a mean follow-up period of 23.5 months. Clinical outcomes, including operative time, blood loss, perioperative complications, postoperative time of hospitalization, neurologic status improvement, back pain and correction of local kyphosis, were investigated by comparing these data with the results from patients who underwent the anterior transthoracic approach for TLDH during the same period. The patients＇ neurologic status was evaluated by a modified Japanese Orthopedic Association （JOA） scoring system of 11 points. Neurologic status improvement after the surgery was assessed by calculating the recovery rate, which was equal to the （postoperative JOA score-preoperative JOA score）/（11-preoperative JOA score）×100%. The rates of patients who improved at the final follow-up were also assessed. Results The mean operative time was 183 minutes, the mean blood loss was 1067 ml, and the mean postoperative hospitalization time was 8.4 days. Three patients suffered perioperative complications, but none of these complications involved the respiratory system. Local kyphotic angles at the fusion levels were reduced. Of the 13 patients that were followed up, 12 improved at the final follow-up, with a mean recovery rate of 52.8%. Patients who underwent the circumspinal decompression procedure showed a higher percentage of improvement at the final follow-up, a higher degree of local kyphosis correction and a lower percentage of complications （especially respiratory complications） compared to patients who underwent the anterior transthoracic decompression procedure. Conclusions The circumspinal decompression through a single posterior incision procedure is an effective and safe technique that is comparable to anterior tranthoracic approach for the surgical treatment of TLDH patients. It could be an attractive choice in certain circumstances.