Name: diagnosis and surgical treatment of human brucellar spondylodiscitis
Uploaded: 2021-05-23T12:30:00.000+00:00
Duration: 6 min 23 s
Description: Watch this Scientific Journal Video about Diagnosis and Surgical Treatment of Human Brucellar Spondylodiscitis at JoVE.com

Dr. Xiaoyu Cai acknowledges the financial support from the China Scholarship Council. This work was funded by the Natural Science Foundation of Xinjiang Province, P. R. China (no. 2016B03047-3).

The study was approved by the ethical committee of the First Affiliated Hospital of Xinjiang Medical University, China17.
1. Informed Consent
<ol>
	<li>Obtain the patient&#39;s informed consent after explaining the details of the surgical procedure, postoperative prognosis, and possible complications (infection, epidural hematoma, spinal cord injury, failure of internal fixation, and cerebrospinal fluid leakage).</li>
	<li>Explain the other risks generally associated with using an implant (e.g., internal fixation system) such as allergic or immune system responses to the implanted materials.</li>
	<li>Rule out any contraindications of the patients.</li>
</ol>
2. Patient selection
<ol>
	<li>Diagnosis of BS
	<ol>
		<li>Base the initial diagnosis of BS on the clinical manifestations and radiographic assessments8.
		<ol>
			<li>Look for clinical manifestations and symptoms such as back pain, undulant fever, malaise, profuse night sweating, weight loss, polyarthralgia, and generalized myalgias8,18.</li>
			<li>In plain radiographs, look for osteophytes, sclerosis, osteoporosis of the vertebral body, and narrowing of the intervertebral disc space, with posterior elements being mostly preserved. 
			NOTE: Central necrosis is mostly not present, and the vertebral body is mostly morphologically intact (Figure 1)18.</li>
			<li>In computed tomography (CT), look for small bone destruction lesions at vertebral edges that occur in multiple areas, and for hyperplastic and sclerotic lesions that are more prominent and often admixed (Figure 1)18. 
			&#8203;NOTE: CT features are divided into those of vertebral osteolysis and vertebral hyperplastic sclerosis stages19.</li>
			<li>As magnetic resonance imaging (MRI) is the best imaging tool for BS diagnosis (Figure 1)20,21,22, look for characteristic MRI findings that can be classified into five subsets: discitis, spondylitis, paraspinal/psoas abscess, appendicitis, and compound (Table 1).</li>
		</ol>
		</li>
		<li>Confirm the diagnosis according to the presence of the following three criteria23:
		<ol>
			<li>Ensure that the clinical picture is compatible with that of BS.</li>
			<li>Confirm the absence of any etiology other than Brucellosis that can explain spinal involvement.</li>
			<li>Confirm that the results of the standard tube agglutination test reveal a titer of antibodies to Brucella of &#8805; 1/16024.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Indications for surgery23
	<ol>
		<li>Look for persistent pain due to spinal instability, which is caused by severe disc or/and vertebral destruction.</li>
		<li>Confirm severe or progressive neurologic dysfunction that can be attributed to nerve root compression by inflammatory granuloma or epidural abscesses.</li>
		<li>Confirm that there is no response to oral antibiotic therapy (e.g., doxycycline, rifampicin, streptomycin).</li>
	</ol>
	</li>
</ol>
3. Preoperative procedure
<ol>
	<li>Administer a chemotherapy regimen (oral doxycycline 200 mg/day plus oral rifampicin 600-900 mg/day)25 to all patients.</li>
	<li>Offer surgical interventions to patients who have surgical indications after two weeks of antibiotic treatment.</li>
</ol>
4. Operative procedures for single-stage transforaminal decompression, debridement, interbody fusion, and internal fixation via posterior-only approach
<ol>
	<li>Place the patient on a four-poster frame in the prone position after administration of general anesthesia with endotracheal intubation.</li>
	<li>Disinfect the surgical area with 1% iodophor, and then cover with standard surgical towels (see Table of Materials).</li>
	<li>Make a midline longitudinal incision over the spinous process of the infected vertebra.</li>
	<li>Expose the posterior spinal structures including lamina, facet joints, and transverse processes.</li>
	<li>Place the pedicle screws (diameter: 5-7 mm, length: 20-65 mm) into both sides of the affected vertebra with the assistance of C-arm fluoroscopy26,27,28 (see Table of Materials). 
	NOTE: To achieve adequate debridement, place the pedicle screws closest to the superior or inferior endplate and away from the infection lesions. Fix the screws to a temporary rod (diameter: 5.5 mm) on the less involved side (see Table of Materials).</li>
	<li>Perform the facetectomy at the involved level on the side where neurologic and radiological manifestations are more severe29.</li>
	<li>Debride the epidural abscess, granulation tissues, infected disc with curettes, and scrape the vertebral endplates. Meanwhile, protect the nerve root with a nerve retractor (see Table of Materials). 
	NOTE: Perform a blunt dissention to adequately drain the psoas abscess from the posterolateral as thoroughly as possible. Analyze the tissues and abscess histopathologically30,31. Noncaseating granulomatous inflammation with predominant lymphocyte and monocytes infiltration is the typical histopathologic finding of BS32. If the result of decompression and debridement is not satisfactory after a unilateral facetectomy, perform the same procedure on the opposite side.</li>
	<li>After adequately removing the lesions and decompressing the neural elements, use 1000-2000 mL of 0.9% sodium chloride solution for surgical area irrigation to clear the residual Brucellar lesion (see Table of Materials).</li>
	<li>Saturate an absorbable gelatin sponge (60 mm x 20 mm x 5 mm) with 0.75-1.5 g of streptomycin, and use it for both hemostasis and local antibiotic treatment within the surgical area (see Table of Materials).</li>
	<li>Implant the locally harvested autogenous bone into the defected space for interbody fusion with a bone graft funnel and bone pusher (see Table of Materials).</li>
	<li>Fix pedicle screws (diameter: 5-7 mm, length: 20-65 mm) on both sides to the pre-contoured rods (diameter: 5.5 mm) under a slight compression33,34 (see Table of Materials).</li>
	<li>Drain and close the lesion35 (see Table of Materials).</li>
</ol>
5. Postoperative management
<ol>
	<li>Administer intravenous antibiotic (cefuroxime sodium, 1.5 g, q12h) for 1-3 days postoperatively.</li>
	<li>Remove the drainage tube when the drainage volume is less than 30 mL per day.</li>
	<li>Administer the aforementioned antibiotic therapies with doxycycline (200 mg/day) and rifampicin (600-900 mg/day) for at least 3 months (range 3-12 months) after surgery.</li>
	<li>Ensure the patient remains in bed for 3-5 days postoperatively, and allow for mobilization by providing effective support with a lumbosacral brace.</li>
	<li>Perform plain radiography before the patient&#39;s discharge to evaluate the location of the graft and instrumentation.</li>
	<li>Ensure at least 2-3 months of brace protection.</li>
</ol>
6. Follow-up evaluation
<ol>
	<li>Follow up with the patients at 1, 3, and 6 months postoperatively and then annually.</li>
	<li>Monitor the infection by measuring erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).</li>
	<li>Evaluate interbody fusion by radiography at the last follow-up. 
	NOTE: Assess graft fusion with the radiologic criteria of Bridwell36. Perform CT scans if there is any uncertainty regarding plain radiographs.</li>
	<li>Utilize the visual analogue scale (VAS) to assess back pain.</li>
	<li>Evaluate pain-related dysfunction with the Oswestry Disability Index (ODI).</li>
	<li>Use the Japanese Orthopedic Association (JOA) scale to evaluate the functional outcomes.</li>
</ol>

The authors have nothing to disclose.

The present guideline of diagnosis and surgical treatment of human BS with a detailed protocol and satisfactory clinical evidence from representative cohorts shows clinical efficacy and is proposed for large-scale application to manage human BS, especially in endemic regions. The first critical step in the treatment of BS is to make the correct diagnosis. The diagnosis of BS needs to be differentiated from spinal tuberculosis compared to which BS is relatively less bone-destructive and usually responds effectively to antibiotic treatment38. In addition, noticeable neurological deficits, persistent pain, spinal instability, and paravertebral abscesses can be observed in BS patients in the later stages. Surgical treatment should be considered as the last resort for patients who do not respond well to antibiotic therapy39. 
Surgical outcomes of BS are rarely elucidated in the literature, and the role of surgery treatment remains controversial. BS typically occurs in the lumbosacral region, particularly at the L4-L5 and L5-S1 levels8,20,40. Surgical debridement, decompression, and fusion via multiple approaches have been proposed14,16,41. As the gold standard, the anterior-only approach ensures a direct access with adequate exposure to the spinal lesion. However, anterior instrumentation at L4-L5 and L5-S1 is potentially dangerous and insubstantial due to the complicated regional anatomy16,41,42. Furthermore, most patients displayed bilateral nerve root compression, epidural abscess formation, and spinal stenosis. Therefore, it may not be possible to achieve complete decompression of the contralateral nerve root via the anterior approach. 
The second critical step is to utilize transforaminal lumbar interbody fusion (TLIF) technology during surgery in the form of a modification of posterior lumbar interbody fusion. This can minimize traction force on the dura and nerve root during surgery and therefore, decrease the risk of postoperative complications43. Posterior-only approaches are reported increasingly as alternative surgical therapy for selective spinal tuberculosis41. Single-stage transforaminal decompression, debridement, interbody fusion, and internal fixation via posterior-only approach is generally reported in the treatment of spinal tuberculosis. However, obtaining adequate debridement and reconstruction of anterior column defects has been considered insufficient. Furthermore, this strategy is also considered unsuitable for patients with severe vertebral collapse and apparent paravertebral abscess formation44,45. 
Unlike spinal tuberculosis, destruction in BS occurs mainly around and within the intervertebral disc, and vertebral collapse and local kyphosis are less likely to occur. Therefore, debridement and intervertebral bone graft fusion via a posterior approach is an effective and safe procedure for BS46. Brucellosis can affect the facets, which may be the reason for severe back pain in these patients. Accordingly, a facetectomy followed by intervertebral debridement and fusion may be more effective than traditional posterior approaches. In this study, no intraoperative complications were observed, and chronic back pain and radiating pain were relieved significantly in the present cohorts after surgery. Besides, no recurrence was reported during the follow-up period. Therefore, this single-stage surgical intervention with transforaminal decompression, debridement, interbody fusion, and internal fixation via the posterior-only approach is clinically effective for surgical candidates of human BS.
The third critical step is to plant the pedicle screw into the affected vertebra to achieve a shorter segmental fixation. The BS lesion mainly involves the structures within the intervertebral space and causes less bony destruction compared to other infectious diseases that occur in the same region. Therefore, the posterior approach has been suggested to be more convenient and minimally invasive during the process to access the involved structures, allowing for a possibly thorough removal of the lesion and complete decompression of bilateral nerve roots. Posterior bone graft implantation can also be straightforwardly performed via the far-lateral portion of vertebral foramen. As BS-related destruction of vertebral body is commonly not severe, the transpedicular screws can still be implanted in the affected vertebra with a minimal surgical exposure and shorter segmental fixation47. In conclusion, application of the aforementioned protocol for timely diagnosis and treatment of BS patients can achieve satisfactory short-term clinical outcomes. Further popularization of this single-stage surgery on a large-scale for surgical candidates, especially in endemic regions, might be helpful to reduce its global burden.

With more than half a million new cases annually, human Brucellosis has become a public health concern and remains an enormous burden worldwide1,2,3,4. BS, as the most common and severe osteoarticular manifestation of human Brucellosis, involves multiple structures including vertebral bodies, intervertebral disc, and paraspinal structures5,6. It occurs frequently in the lumbosacral zone and needs to be differentiated from other infectious diseases because of its nonspecific clinical characteristics7,8. Despite the significant advances in research over the past decades, accurate and timely diagnosis of BS is still a challenge for clinicians due to its late-onset radiological findings, slow growth rate in blood cultures, and the complexity of its serodiagnosis9. Therefore, human BS remains clinically underdiagnosed and underreported. Although the past decades have seen increasingly rapid advances in the introduction and popularization of several therapeutic guidelines, there is still no consensus for an optimal management modality10. Frequent relapses, treatment failure, and sequelae are reported constantly11.
Of note, BS can be severely debilitating and disabling even if it is rarely fatal. If it is not treated appropriately, possible serious sequelae might be induced including persistent back pain, neurological deficiency, and even kyphotic deformity12,13. Antibiotic therapy is the core in the treatment of BS and yields generally promising outcomes9. However, certain patients may require surgical treatment if neurological dysfunction, spinal instability, abscess formation, intractable pain, or a previous unsatisfactory response to conservative treatments are observed. Surgical intervention remains controversial. Different surgical procedures for debridement and fusion have been described for infectious diseases of the lumbar spine including anterior-only, posterior-only, and combined approaches14,15,16. Here, diagnostic guidelines have been presented for human BS and for the single-stage surgical treatment with transforaminal decompression, debridement, interbody fusion, and internal fixation via a posterior-only approach. A detailed protocol of this method is given below.

<table><tbody><tr><td>Absorbable gelatin sponge</td><td>Chuhe Medical Devices Co., Ltd.</td><td>AWZ-035-XSMJHM-AD.</td><td>60 mm x 20 mm x 5 mm</td></tr><tr><td>Box curette&amp;nbsp;</td><td>Rudischhauser GmbH</td><td>R16-BD2310-ST</td><td>Width: 7.5 mm; height: 5.9 mm; shaft: 6.0 mm (diameter); working length: 223 mm</td></tr><tr><td>Bone graft funnel&amp;nbsp;</td><td>Rudischhauser GmbH</td><td>R19-K00000-FU</td><td>Working length: 246.5 mm; End diameter: 42 mm; shaft: 6.4 mm (diameter)</td></tr><tr><td>Bone pusher&amp;nbsp;</td><td>Rudischhauser GmbH</td><td>R19-EK4110-00</td><td>Working length: 220 mm; shaft: 6.0 mm (diameter)</td></tr><tr><td>Bone rongeur</td><td>Vet Direct &amp;amp; VETisco</td><td>EC-RG-BO-180</td><td>Length: 180 mm</td></tr><tr><td>Iodophor (1%)</td><td>Beijing SanYao Science &amp;amp; Technology Development Co.</td><td>14975I</td><td>Volume: 500 mL</td></tr><tr><td>Nerve retractor</td><td>Rudischhauser GmbH</td><td>R16-HD1710-00</td><td>Width: 10 mm; length: 145 mm; shaft: 5.0 mm (diameter)</td></tr><tr><td>Osteotome 1</td><td>Rudischhauser GmbH</td><td>R16-CD2310-08</td><td>Width: 8 mm; height: 3 mm; shaft: 6.0 mm (diameter); working length: 223 mm</td></tr><tr><td>Osteotome 2</td><td>Rudischhauser GmbH</td><td>R16-CD2310-10</td><td>Width: 10 mm; height: 3 mm; shaft: 6.0 mm (diameter); working length: 223 mm</td></tr><tr><td>Pedicle screw</td><td>DePuy Synthes Companies</td><td>199723540</td><td>Length: 40 mm; diameter: 5.0 mm</td></tr><tr><td></td><td>DePuy Synthes Companies</td><td>199723545</td><td>Length: 45 mm; diameter: 5.0 mm</td></tr><tr><td></td><td>DePuy Synthes Companies</td><td>199723550</td><td>Length: 50 mm; diameter: 5.0 mm</td></tr><tr><td></td><td>DePuy Synthes Companies</td><td>199723640</td><td>Length: 40 mm; diameter: 6.0 mm</td></tr><tr><td></td><td>DePuy Synthes Companies</td><td>199723645</td><td>Length: 45 mm; diameter: 6.0 mm</td></tr><tr><td></td><td>DePuy Synthes Companies</td><td>199723650</td><td>Length: 50 mm; diameter: 6.0 mm</td></tr><tr><td></td><td>DePuy Synthes Companies</td><td>199723740</td><td>Length: 40 mm; diameter: 7.0 mm</td></tr><tr><td></td><td>DePuy Synthes Companies</td><td>199723745</td><td>Length: 45 mm; diameter: 7.0 mm</td></tr><tr><td></td><td>DePuy Synthes Companies</td><td>199723750</td><td>Length: 50 mm; diameter: 7.0 mm</td></tr><tr><td>Securo Drain</td><td>Dispomedica GmbH</td><td>1.33578</td><td>Size: 7 mm; Length of perforation: 15 cm; Total length: 80 cm; Reservior size: 150 ml</td></tr><tr><td>Sterile 0.9% Sodium Chloride Solution</td><td>Beijing SanYao Science &amp;amp; Technology Development Co.</td><td>15935S</td><td>Volume: 500 mL</td></tr><tr><td>Straight rod</td><td>DePuy Synthes Companies</td><td>1797-62-480</td><td>Length: 480 mm; diameter: 5.5 mm</td></tr><tr><td>Streptomycin sulfate, Powder</td><td>Beijing SanYao Science &amp;amp; Technology Development Co.</td><td>P06-11025P</td><td>Size: 1 g</td></tr></tbody></table>

diagnosis and surgical treatment of human brucellar spondylodiscitis

Brucellar spondylodiscitis (BS) is the most prevalent and significant osteoarticular presentation of human Brucellosis, which is commonly manifested in pastoral communities. It is difficult to differentially diagnose and usually leads to irreversible neurologic deficits and spinal deformities. The initial diagnosis of BS is based on clinical findings and radiographic assessments, and the confirmed diagnosis should be established by the isolation of Brucella species from the blood and/or the standard tube agglutination test. Differential diagnosis of multifocal BS from either degenerative disc diseases or tuberculosis is especially highlighted. The surgical approach, either endoscopic or open, is demonstrated in detail, accompanied by radiographic evidence of structural compression or severe instability. Further, the crucial surgical steps, including single-stage transforaminal decompression, debridement, interbody fusion, and internal fixation, are explained. Moreover, perioperative care and postoperative rehabilitation are also addressed. Taken together, this clinical algorithm presents a practical guide that has yielded substantially satisfactory outcomes in the past decades, which can also be introduced for large-scale application to manage human BS, especially in endemic regions.

This paper describes a prospective, non-randomized, controlled study of 32 consecutive BS patients who were treated by a single-stage transforaminal decompression, debridement, interbody fusion, and internal fixation via a posterior-only approach in the Department of Spine Surgery, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China. Figure 1 shows a typical case in this study.
The clinical symptoms are summarized in Table 2. Patients generally complained of chronic back pain with signs of neurological impairment. Brucella agglutination level was &#8805;1/160 in all patients; positive blood culture results were observed in 8 cases (25%). According to the aforementioned diagnostic criteria, all patients were indicated as candidates for a single-stage surgical treatment. The mean duration of surgery was 133.1 &#177; 36.6 min, and the mean blood loss was 378.1 &#177; 187.9 ml (range 120-800 mL). Histopathologic examinations on biopsy samples obtained from the paravertebral tissue indicated noncaseating granulomatous lesions infiltrated by inflammatory cells (lymphocyte and monocytes) with various spatial extents (Figure 2). Patients were followed up for over 12 months (24.9 &#177; 8.2 months). Postoperative complications, including superficial wound infection, was seen in 1 patient at postoperative day 10 and treated successfully with intravenous antibiotics. Deep wound infection and sinus formation were perceived in 2 patients with a history of diabetes and treated by a revision surgery and extended intravenous antibiotics. No clinical or radiological relapses were observed throughout the entire follow-up phase.
Radiating pain were immediately relieved after surgery, and significant decrease in constitutional symptoms was achieved within the first postoperative month. ESR and CRP levels returned to normal levels by the third postoperative month. The preoperative levels of ESR (46.03 &#177; 12.73) and CRP (41.47 &#177; 41.74) declined to 8.86 &#177; 3.05 and 4.56 &#177; 1.75, respectively, in postoperative month 3. The significant improvement in VAS, ODI, and JOA scores between the preoperative assessment and final follow-up are shown in Table 3.
The interbody fusion rate was 93.8% at 12 months postoperatively according to the Bridwell criteria. Grade I and II fusion was seen in 30 (93.75%) and 2 patients (6.25%), respectively. These two patients with grade II fusion were evaluated with lateral flexion/extension radiography and CT examinations; no noticeable movement or gap was detected within the interbody area.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/61840/61840fig01.jpg" /> 
Figure 1: A 69-year-old male presented with L3-L4 Brucellar spondylodiscitis. (A) Anteroposterior view shows hyperplastic changes on the lateral edge of the L3-L4 vertebral body and formation of osteophytes (arrow). (B) Lateral view shows disc space narrowing and anterior osteophyte formation (parrot&#39;s beak). (C, D) Sagittal T1- and T2-weighted MRI shows lesions involved in L3-L4 vertebral bodies and intervertebral disc, accompanied by epidural abscess and inflammatory granuloma formation. (E, F) Transverse MRI and CT demonstrate spinal canal stenosis. (G, H) Postoperative plain radiograph shows intervertebral bone grafting and instrumentation. (I) Twelve-month postoperative X-ray showed a firm fixation and interbody fusion. This figure has been modified from Abulizi et al.37. Abbreviations: MRI = magnetic resonance imaging; CT = computed tomography. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61840/61840fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/61840/61840fig02.jpg" /> 
Figure 2: Histological analysis of lesion biopsies. Hematoxylin and eosin staining shows lymphocyte and monocyte infiltration in the samples biopsied from affected paravertebral tissue. Yellow arrows indicate lymphocytes, and red arrows indicate monocytes. Scale bar = 50 &#181;m.&#160;<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61840/61840fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Classification</td>
			<td>MRI characteristics</td>
		</tr>
		<tr>
			<td rowspan="3">Discitis</td>
			<td>Regional inflammation involving intervertebral disc</td>
		</tr>
		<tr>
			<td>Disc space narrowing</td>
		</tr>
		<tr>
			<td>Low signal on T1-weighted image mixing high signal on T2-weighted image</td>
		</tr>
		<tr>
			<td rowspan="3">Spondylitis</td>
			<td>Regional inflammation involving adjacent vertebrae</td>
		</tr>
		<tr>
			<td>Vertebrae diffuse marrow edema</td>
		</tr>
		<tr>
			<td>Homogeneous or uneven low signal on T1-weighted image of vertebrae</td>
		</tr>
		<tr>
			<td rowspan="3">Paraspinal/psoas abscess</td>
			<td>Regional inflammation involving paraspinal or psoas</td>
		</tr>
		<tr>
			<td>Paravertebral abscess</td>
		</tr>
		<tr>
			<td>Psoas abscess</td>
		</tr>
		<tr>
			<td rowspan="3">Appendicitis</td>
			<td>Regional inflammation involving appendicitis</td>
		</tr>
		<tr>
			<td>Low signal on T1-weighted image</td>
		</tr>
		<tr>
			<td>High signal on T2-weighted image</td>
		</tr>
		<tr>
			<td rowspan="3">Compound</td>
			<td>Endemic inflammation involving two or more parts of vertebral and paravertebral structures</td>
		</tr>
		<tr>
			<td>T1-weighted image reveals incomplete heterogeneous hypointensity</td>
		</tr>
		<tr>
			<td>T2-weighted image reveals hyperintensity</td>
		</tr>
		<tr>
			<td colspan="2">This table has been modified from Bai et al.22.</td>
		</tr>
	</tbody>
</table>
Table 1.&#160;Classification of Brucellar spondylodiscitis for MRI.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Symptoms</td>
			<td>Number of patients (%)</td>
		</tr>
		<tr>
			<td>Spinal symptoms</td>
			<td></td>
		</tr>
		<tr>
			<td>-Back pain</td>
			<td>31 (96.9%)</td>
		</tr>
		<tr>
			<td>-Radiculopathy</td>
			<td>22 (68.8%)</td>
		</tr>
		<tr>
			<td>Constitutional symptoms</td>
			<td></td>
		</tr>
		<tr>
			<td>-Fever</td>
			<td>27 (84.4%)</td>
		</tr>
		<tr>
			<td>-Sweating</td>
			<td>18 (56.3%)</td>
		</tr>
		<tr>
			<td>-Weakness of fatigue</td>
			<td>14 (43.8%)</td>
		</tr>
		<tr>
			<td>-Weight loss</td>
			<td>9 (28.1%)</td>
		</tr>
		<tr>
			<td>-Hepatomegaly</td>
			<td>7 (21.9%)</td>
		</tr>
		<tr>
			<td>-Arthralgia</td>
			<td>4 (12.5%)</td>
		</tr>
		<tr>
			<td colspan="2">This table has been modified from Abulizi et al.37.</td>
		</tr>
	</tbody>
</table>
Table 2.&#160;Clinical characteristics of 32 patients.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Parameters</td>
			<td>Preoperative</td>
			<td>Last follow-up</td>
			<td>Improvement rate (%)</td>
			<td>P value</td>
		</tr>
		<tr>
			<td>VAS</td>
			<td>5.19 &#177; 1.47</td>
			<td>0.47 &#177; 0.67</td>
			<td>90.9</td>
			<td>&#60;0.05</td>
		</tr>
		<tr>
			<td>ODI</td>
			<td>55.31 &#177; 9.16</td>
			<td>10.72 &#177; 3.23</td>
			<td>80.7</td>
			<td>&#60;0.05</td>
		</tr>
		<tr>
			<td>JOA</td>
			<td>12.38 &#177; 2.98</td>
			<td>26.13 &#177; 2.58&#160;</td>
			<td>82.7</td>
			<td>&#60;0.05</td>
		</tr>
		<tr>
			<td colspan="5">Scores were demonstrated as Mean &#177; Standard deviation. Abbreviations: VAS = visual</td>
		</tr>
		<tr>
			<td colspan="5">analogue scale; ODI = Oswestry Disability Index; JOA = Japanese Orthopaedic Association.</td>
		</tr>
		<tr>
			<td colspan="4">This table has been modified from Abulizi et al.37.</td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 3.&#160;Comparison of preoperative and last follow-up VAS, ODI, JOA scores.

Watch this Scientific Journal Video about Diagnosis and Surgical Treatment of Human Brucellar Spondylodiscitis at JoVE.com

Diagnosis and Surgical Treatment of Human Brucellar Spondylodiscitis

We describe a clinical algorithm, based on decades of front-line experience of diagnosis and surgical treatment of human Brucellar spondylodiscitis in the largest medical center of the China's Xinjiang Pastoral Area.

Brucellar spondylodiscitis (BS) is the most prevalent and significant osteoarticular presentation of human Brucellosis, which is commonly manifested in ...

diagnosis-and-surgical-treatment-of-human-brucellar-spondylodiscitis

Nanyang Technological University

Research

JoVE Journal

Medicine

4.8K Views.  First Affiliated Hospital of Xinjiang Medical University. Diagnose en chirurgische behandeling voor menselijke Brucellar Spondylodiscitis. Brucellar spondylodiscitis is een van de meest voorkomende en ernstige articulaire presentatie van menselijke brucellose. De klinische kenmerken van BS zijn niet-specifiek en kunnen overlappen met een breed spectrum van andere infectieuze en niet-infectieuze ziekten.Hoewel sommige nieuwe therapeutische richtlijnen in de literatuur worden aanbevolen, blijven het optimale behandelingsregime en de duur van an...

Video: Diagnosis and Surgical Treatment of Human Brucellar Spondylodiscitis

Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is performed under general anesthesia and neuromonitoring. The patient is placed in a prone position on an operating carbon table. A navigation reference frame is placed percutaneously into the contralateral sacroiliac joint or spinous process. Then, CT scan images are obtained. After instrument registration, the L5-S1 foraminal level is confirmed with a navigated probe, and the entry point is marked. Using an approximately 2 cm skin incision, the subcutaneous tissue and muscles are dissected. The navigated first dilator is aimed at the L5-S1 Kambin&#39;s triangle, and sequential dilation is performed. The 18 mm tube is used and fixed to the frame. The bone around the Kambin&#39;s triangle is removed with a navigated burr. For lateral disc herniation, the L5 nerve root is identified and retracted, and the disc fragment is removed. The navigation-guided tubular endoscopic decompression is an effective procedure. There is no radiation hazard to the surgeon or the operating room staff.

Presented here is a novel technique of C-arm free transtubular posterolateral decompression for lumbar foraminal stenosis and lateral disc herniation under O-arm navigation.

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is ...

Neuroscience

Full Endoscopic Interlaminar Approach for Paracentral L5-S1 Disc Herniation

The full endoscopic interlaminar approach (FEILA) is a minimally invasive technique for lumbar discectomy. It has multiple advantages over other conventional discectomy methods, including less traumatization of the soft tissues, fewer complication rates (dural injury, bleeding), rapid rehabilitation, quick return to daily life activities, and preferable cosmetic results. FEILA is a surgery with a relatively steep learning adaptation. Endoscopic surgery is a closed tubular approach, and all surgical maneuvers are performed within a uniportal single working channel. Also, the technique has not yet been standardized and well-documented. Therefore, the early learning stages of this technique may not be easy for most surgeons. Despite these, FEILA is easy, and the operation length is comparable to and even shorter than other techniques of lumbar discectomy. FEILA for lumbar discectomy could be considered a safe and effective alternative procedure for paracentral L5-S1 disc herniation. Here, we describe the technique of FEILA, including every cutoff step required to reach technical proficiency for surgeons who want to start applying this approach.

Here, we present a protocol to describe the full endoscopic interlaminar approach (FEILA) technique, including every cutoff step required to reach technical proficiency. FEILA is a surgery with a relatively steep learning adaptation. Despite this, any surgeon capable of microdiscectomy can perform FEILA with enough practice and suitable patient selection.

The full endoscopic interlaminar approach (FEILA) is a minimally invasive technique for lumbar discectomy. It has multiple advantages over other ...

Full-Endoscopic Isolation Zone Technique for the Treatment of Lumbar Disc Herniation

Lumbar disc herniation (LDH) is a type of serious sinus or sciatic nerve dysfunction caused by nucleus pulposus protrusion and annulus fibrosus tears. Its clinical symptoms often include severe low back pain, limited lumbar movement, sciatic nerve pain in the lower limbs, and even cauda equina syndrome. The common treatment for LDH is a conservative treatment scheme involving medicine, rest, and physical therapy. However, if the conservative treatment scheme is ineffective, a surgical treatment approach is adopted. Traditional open lumbar surgery has some disadvantages, including the potential for severe surgical trauma, severe blood loss during the operation, instability of the lumbar spine, and loss of the lumbar motor unit. Among the minimally invasive surgical schemes, full-endoscopic spine surgery (FESS) is undoubtedly the most appropriate and has the advantages of minimal trauma, high safety, quick postoperative recovery, and the retention of the stable structure and the motor unit of the lumbar spine. However, simultaneously, incomplete removal of the nucleus pulposus and residual nerve dysfunction after surgery can occur. To avoid these shortcomings, we studied a specific spinal endoscopy technique, the "isolation zone" surgical strategy, which can effectively block the pain from the nerve conduction pathway by completely relieving the nerve compression and nerve dysfunction through the orderly treatment of the protruding nucleus pulposus, the fissure of the annulus fibrosus, the sinus nerve, and the surrounding inflammatory soft tissues.

Here, we present a protocol for the &#34;isolation zone&#34; technique in the treatment of lumbar disc herniation (LDH) under full-endoscopic spine surgery (FESS), including intervertebral foramen formation, targeted catheterization, nucleus pulposus resection, and annulus fibrosus formation, which together completely block the pain from the nerve conduction pathway.

Lumbar disc herniation (LDH) is a type of serious sinus or sciatic nerve dysfunction caused by nucleus pulposus protrusion and annulus fibrosus tears. Its ...

Anterior Cervical Hybrid Decompression and Fusion Surgery to Treat Multilevel Cervical Spondylotic Myelopathy

Cervical spondylotic myelopathy (CSM) is a common disease resulting from intervertebral disc herniation, ossification of the posterior longitudinal ligament, and other pathological changes that cause spinal cord compression. CSM progresses insidiously with mild upper-limb numbness, which patients tend to ignore. As the condition worsens, the patients may experience a limp, limited fine motor activity, and eventually, a loss of daily activity. Conservative treatments, such as physical therapy and medication, are frequently ineffective for CSM. Once surgery is deemed to be required, decompression surgery is the best option. So far, both anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) have been commonly used to treat CSM. In addition, a type of hybrid procedure that combines ACDF with ACCF has been used to treat some CSM cases and achieved satisfying results. Thus, this study aims to introduce this hybrid surgical technique and advocate for it based on its patient success.

This paper describes a hybrid surgical technique that combines anterior cervical discectomy and fusion with anterior cervical corpectomy and fusion to treat patients with multilevel cervical spondylotic myelopathy.

Cervical spondylotic myelopathy (CSM) is a common disease resulting from intervertebral disc herniation, ossification of the posterior longitudinal ...

Unilateral Biportal Endoscopy for the Treatment of Lumbar Disc Herniation

Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery technique increasingly employed in treating degenerative lumbar diseases, such as lumbar disc herniation, lumbar spinal stenosis, and spondylolisthesis. In UBE, two independent yet interconnected surgical channels are established-one for the endoscope and the other for surgical instruments-providing a broad and clear surgical field of view. UBE offers several advantages over traditional open surgery, including reduced tissue damage, shorter hospital stays, and faster recovery times. Additionally, it combines the benefits of microscopic surgery and interlaminar endoscopy, enhancing flexibility, accuracy, and reliability during the procedure. The learning curve for UBE is shorter than that for transforaminal endoscopy, as the surgical processes closely resemble those of conventional open surgery. Despite its favorable clinical outcomes, such as reduced blood loss and shorter hospitalization, UBE carries potential complications, including epidural hematoma, dural injury, and compression of the outlet nerve root. To mitigate these risks, it is crucial to ensure appropriate patient selection, apply the correct surgical technique, and engage in careful postoperative monitoring. This article provides a detailed summary of the step-by-step surgical techniques used in UBE for treating lumbar disc herniation. It serves as a comprehensive guide to enhance practitioners' understanding of UBE. The presentation also underscores the importance of rigorous training and expertise to ensure optimal patient outcomes.

Presented here is a step-by-step surgical protocol of unilateral biportal endoscopy (UBE), a minimally invasive approach for treating lumbar disc herniation. By using two ports, surgical accuracy and flexibility are enhanced. This article provides a comprehensive description of UBE and highlights the practical application of this approach in clinical practice.

Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery technique increasingly employed in treating degenerative lumbar diseases, such ...

A Modified Eggshell Technique for Sclerosing Thoracic Disc Herniation

Sclerosing thoracic disc herniation refers to a condition in which the intervertebral disc in the thoracic region protrudes and becomes calcified, causing compression on the spinal cord and/or nerve roots. Sclerosing herniation of the thoracic disc poses a significant danger as it can lead to serious complications like paraplegia during or after surgery. Iatrogenic spinal cord injury is a common risk for individuals diagnosed with sclerosing thoracic disc herniation due to the inflexible protrusion of the sclerosing disc into the spinal canal and its adhesion to the ventral side of the dural sac. The challenging and crucial aspect of the surgery is how to safely and efficiently eliminate the hardened tissue. The eggshell method is a surgical procedure that addresses the kyphosis abnormality of the spinal column by excavating the vertebral body via the pedicles and subsequently inserting the kyphotic fracture block into the excavated vertebral body. In this article, a revised surgical method using the eggshell technique will be presented for the treatment of sclerosing thoracic disc herniation. The surgical procedure briefly involves hollowing out the anterior intervertebral space of the hardened disc tissue to create an eggshell-like structure, with the sclerotic tissue forming the posterior wall. Subsequently, the sclerotic disc tissue is pushed into the hollow intervertebral space to achieve complete decompression of the ventral spinal cord. The safety and effectiveness of this approach for treating sclerosing thoracic disc herniation have been confirmed.

This protocol introduces a modified eggshell surgical technique used for treating sclerosing thoracic disc herniation.

Sclerosing thoracic disc herniation refers to a condition in which the intervertebral disc in the thoracic region protrudes and becomes calcified, causing ...

Novel PLL-AF Suture Technique for Annulus Fibrosus Repair in Lumbar Endoscopy

A Suture Technique for Ruptured Annulus Fibrosus Following Decompression Under Percutaneous Transforaminal Endoscopic Discectomy

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full decompression has been shown to decrease the recurrence rate of lumbar disc herniation during endoscopic surgery. Traditional suture operations under endoscopy involve only simple suturing of the ruptured AF. Due to the weak and poor quality of the AF tissue around the tear portal, using this area as needle insertion points during suturing may lead to insufficient tension and a low success rate of AF closure. Currently, there is no detailed technical illustration based on video for AF tear suturing under lumbar full-endoscopy. We innovatively propose a method of covering and suturing the AF tear by pulling up the posterior longitudinal ligament (PLL) under lumbar endoscopy and using three stitches (PLL-AF suture technique). The patient who received the novel suture technique achieved satisfactory results. Six months after the operation, lumbar MRI showed no evidence of recurrence in the outpatient clinic.

Author Spotlight: Development and Application of a Novel Suture Technique for Annular Fibrosus Repair in Percutaneous Transforaminal Endoscopic Discectomy

This protocol describes an innovative suture technique for ruptured annular fibrosus during percutaneous transforaminal endoscopic discectomy.

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full ...

Full-Endoscopic Foraminoplasty and Lumbar Discectomy for Single-Level Lumbar Disc Herniation

The Transforaminal Endoscopic Surgical System (TESSYS) technique has gained popularity for the treatment of lumbar disc herniations. Foraminoplasty is the key procedure in TESSYS. However, it requires advanced skills and long-term learning, which hinder its widespread adoption among surgeons. Recently, the introduction of full-endoscopic solutions has made the process more manageable. The main difference from traditional single-portal endoscopic surgery is that full-endoscopic surgery is equipped with a larger working channel, allowing full visualization of foraminoplasty and decreasing reliance on intraoperative fluoroscopy. Recently, published studies have shown that full-endoscopic foraminoplasty and lumbar discectomy (FEFLD) could achieve comparable results to conventional microdiscectomy in terms of pain relief and functional outcomes, while enhancing postoperative recovery. This study describes the technique of FEFLD in detail, including every crucial step, such as patient positioning, puncture trajectory, endoscopic dissection of the superior articular process (SAP), endoscopic foraminoplasty, and more. We hope this will be helpful to beginners who wish to apply this approach.

Compared to conventional transforaminal endoscopic surgery, full-endoscopic foraminoplasty and lumbar discectomy (FEFLD) is a unique technique that allows full visualization of foraminoplasty and reduces the need for intraoperative fluoroscopies. This article describes the surgical steps involved in the FEFLD technique, shedding light on surgical tips and potential pitfalls to ensure outstanding performance.

The Transforaminal Endoscopic Surgical System (TESSYS) technique has gained popularity for the treatment of lumbar disc herniations. Foraminoplasty is the ...

A Retrospective Study on Endoscopic Surgery for the Treatment of Paravertebral Abscess in Spinal Tuberculosis Patients

Spinal tuberculosis (TB) remains a significant global health concern, necessitating the development of innovative treatment strategies. This clinical study aimed to evaluate the efficacy and safety of endoscopic debridement as a minimally invasive approach for treating paravertebral abscesses in patients with spinal tuberculosis. A total of 52 patients diagnosed with paravertebral tuberculosis abscesses were enrolled in this retrospective study. Patients were assigned to two groups: the endoscopic debridement group (n = 30) and the conventional open surgery group (n = 22), based on the type of surgery they received. Clinical outcomes were assessed at baseline, post-treatment, and follow-up visits at regular intervals, including surgery time, intraoperative blood loss, total hospital stay duration, pain relief, and neurological improvement. The results of this study demonstrate that endoscopic debridement is a highly effective treatment for paravertebral abscesses in patients with spinal TB. Patients in the endoscopic debridement group experienced significant improvements in surgery time, intraoperative blood loss, total hospital stay duration, pain relief, and neurological improvement compared to those in the conventional open surgery group. Additionally, the endoscopic approach resulted in fewer complications, such as wound infections and postoperative instability, with no cases of recurrence observed during the follow-up period. Therefore, this clinical study highlights the potential of endoscopic debridement as a safe and effective treatment modality for spinal tuberculosis. The technique not only effectively eliminates infected tissue but also ensures faster patient recovery and reduces postoperative complications. Additional research and long-term follow-up studies are necessary to confirm the long-term effectiveness and safety of endoscopic debridement as the standard treatment for spinal tuberculosis.

This study evaluated endoscopic debridement for treating paravertebral abscesses in patients with spinal tuberculosis. Compared to conventional surgery, it significantly improved surgery time, blood loss, hospital stay, pain relief, and neurological outcomes, with fewer complications and no recurrences. These findings highlight its efficacy and safety. Further long-term studies are recommended.

Spinal tuberculosis (TB) remains a significant global health concern, necessitating the development of innovative treatment strategies. This clinical ...

Technique of Sagittal Adjusting Screw System for Thoracolumbar Burst Fractures

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the indication for surgical treatment of neurologically intact TL fractures remains under debate, studies have demonstrated that posttraumatic malalignment may lead to a deterioration in the patient&#39;s quality of life. For burst fractures with malalignment or fragments in the spinal canal, a reduction technique using ligamentotaxis is commonly used to improve long-term outcomes.
The sagittal adjusting screw (SAS) system is a monoaxial screw system with a fixed head and concave sliding saddle that allows lordotic sliding of the rod in the sagittal plane after screw insertion. SAS also has a percutaneous option and has been used for TL spine fractures. Notably, the SAS only allows motion on the sagittal plane, allowing both secure fixation and angular reduction. The SAS has certain advantages over the conventional Schanz screw system or normal mono-/multiaxial pedicle screws for TL spine fracture treatment. In addition, specialized trauma reduction devices are available for the SAS system. In this video protocol, we discuss the indication for the SAS system in TL burst fracture and describe a technique of TL burst fracture reduction and fixation using the SAS system. Additionally, we describe our recent case series with radiological evaluation, including regional kyphotic angle and percent loss of anterior vertebral body height, to evaluate the newly introduced trauma reduction device.

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.

Diagnosis and Surgical Treatment of Human Brucellar Spondylodiscitis

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