Infectious Diseases Society of America.

Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a ‘cold’ abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.

/pdf/spinal-tuberculosis-a-review-c996lhzpsx.pdf

Spinal tuberculosis: A review

Background Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians. Objective To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain. Design Systematic assessment of the literature. Methods Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II. Outcomes Short-term pain relief was defined as relief lasting at least 6 months and long-term relief was defined as longer than 6 months, except for intradiscal therapies, mechanical disc decompression, spinal cord stimulation and intrathecal infusion systems, wherein up to one year relief was considered as short-term. Results The indicated evidence for accuracy of diagnostic facet joint nerve blocks is Level I or II-1 in the diagnosis of lumbar, thoracic, and cervical facet joint pain. The evidence for lumbar and cervical provocation discography and sacroiliac joint injections is Level II-2, whereas it is Level II-3 for thoracic provocation discography. The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. The evidence is Level I or II-1 for percutaneous adhesiolysis in management of pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in managing pain of post-lumbar surgery syndrome, and lumbar spinal stenosis, for cervical interlaminar epidural injections in managing cervical pain (Level II-1); for lumbar transforaminal epidural injections; and spinal cord stimulation for post-lumbar surgery syndrome. The indicated evidence for intradiscal electrothermal therapy (IDET), mechanical disc decompression with automated percutaneous lumbar discectomy (APLD), and percutaneous lumbar laser discectomy (PLDD) is Level II-2. Limitations The limitations of these guidelines include a continued paucity of the literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines by various organizations. Conclusion The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. Further, these guidelines also do not represent "standard of care."

/pdf/comprehensive-evidence-based-guidelines-for-interventional-25v98tginx.pdf

Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain

/pdf/comprehensive-evidence-based-guidelines-forinterventional-42xrrh561x.pdf

Comprehensive Evidence-Based Guidelines forInterventional Techniques in the Managementof Chronic Spinal Pain

Background Chronic neck pain is a common problem in the adult population with a typical 12-month prevalence of 30% to 50%, and 14% of the patients reporting grade II to IV neck pain with high pain intensity and disability that has a substantial impact on health care and society. Cervical epidural injections for managing chronic neck pain are one of the commonly performed interventions in the United States. However, the literature supporting cervical epidural steroids in managing chronic pain problems has been scant and no systematic review dedicated to the evaluation of cervical interlaminar epidurals has been performed in the past. Study design A systematic review of cervical interlaminar epidural injections. Objective To evaluate the effect of cervical interlaminar epidural injections in managing various types of chronic neck and upper extremity pain emanating as a result of cervical spine pathology. Methods The available literature of cervical interlaminar epidural injections in managing chronic neck and upper extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF) for therapeutic interventions. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. Outcome measures The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results The indicated evidence is Level II-1 in managing chronic neck and upper extremity pain with 1C/strong recommendation. Limitations The limitations of this systematic review include the paucity of literature and lack of randomized trials performed under fluoroscopy. Conclusion The results of this systematic evaluation of cervical interlaminar epidural injection showed significant effect in relieving chronic intractable pain of cervical origin and also providing long-term relief with an indicated evidence level of Level II-1.

/pdf/systematic-review-of-the-effectiveness-of-cervical-epidurals-5lggsndatg.pdf

Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain.

External fixation was used in the treatment of 154 intertrochanteric fractures of the femur over a period of eight years. Good fixation and early ambulation was achieved in all cases. Blood loss was slight. There were 12 deaths due to medical causes unrelated to the surgical procedure. Deep pin-track infection occurred in six cases and late displacement of the fracture fragments in nine. The average time for union was 16 weeks. The technique is simple, quick and inexpensive, and causes minimal surgical trauma. All these features are particularly relevant where resources are limited.

External fixation of intertrochanteric fractures of the femur

A 24-year-old woman presented with sudden onset severe pain in both groins and inability to stand without support. She had had some groin discomfort for the past few weeks on walking. She had a sedentary lifestyle and took no strenuous exercise. She had no history of trauma or seizures. She was not on any medication and had no history

https://www.tandfonline.com/doi/pdf/10.1080/000164701753606770

Spontaneous bilateral displaced femoral neck fractures in nutritional osteomalacia--a case report.

Case report Spontaneous bilateral displaced femoral neck fractures in nutritional osteomalacia—a case report

Thirteen pseudoaneurysms are presented of which five were caused as a complication of pin/wire placement of external fixators (one conventional and four Ilizarov frames). The most common symptom was the presence of profuse persistent bleeding from either the wound or the pin/wire site. In nine patients the pseudoaneurysm was directly caused by a fracture or subsequent fracture stabilisation. Pre-operative evaluation included radiography, arteriography, Doppler and computed tomography (CT) angiography. Depending on the site and size of the pseudoaneurysm management consisted of either ligation, resection and end-to-end anastamosis/vein grafting, lateral suture, endoaneurysmorrhaphy or selective embolisation. A high index of suspicion needs to be maintained following penetrating injury in the vicinity of a major vessel, particularly in the presence of persisting symptoms. External fixators are widely used to treat complex orthopaedic problems. The procedure is technically demanding, requiring a sound knowledge of cross-sectional limb anatomy. Injudicious use may result in potentially life/limb threatening complication of pseudoaneurysm.

Encounters with pseudoaneurysms in orthopaedic practice.

Background: There is scarce information on craniovertebral junction tuberculosis even in developing countries The pendulum of treatment in craniovertebral junction tuberculosis has periodically vacillated between nonoperative management and radical surgery

Methods: We performed a retrospective review of prospectively collected clinical and radiographic data on twenty-six consecutive patients with craniovertebral junction tuberculosis who were treated nonoperatively in our institution The patients who had weakness of the limbs, pyramidal signs, or evidence of atlantoaxial dislocation and/or basilar invagination were immediately managed with immobilization with Crutchfield tongs traction (Group A), followed by halo-vest application Patients without a neurological deficit, pyramidal signs, or atlantoaxial dislocation or basilar invagination were treated with cervical immobilization with early application of a halo vest (Group B)

Results: The common presenting features were neck pain, restriction of neck movement, and spastic weakness of limbs A retropharyngeal purulent fluid collection and osseous involvement of the dens and lateral mass of the atlas were the common radiographic findings Twelve patients were partially or completely dependent on others for activities of daily living, and marked ligamentous and bone destruction with displacement at the atlantoaxial level was seen in eight patients at the time of presentation The twenty patients in group A had cervical traction for a mean of 59 weeks, and a halo vest was applied for a mean of 69 months with antitubercular therapy for eighteen months The mean follow-up period was 252 months (range, eighteen to forty-two months) All of the patients were independent in activities of daily living at the time of the last follow-up

Conclusions: In the Indian subcontinent, the disease process of craniovertebral junction tuberculosis is usually quite advanced at the time of presentation On the basis of our study, patients with craniovertebral junction tuberculosis can be managed successfully with nonoperative treatment even with advanced involvement of bone or soft tissues at this spinal level

Level of Evidence: Therapeutic Level IV See Instructions to Authors for a complete description of levels of evidence

The Results of Nonoperative Treatment of Craniovertebral Junction Tuberculosis: A Review of Twenty-six Cases

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