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1.  Surgical management of sternoclavicular septic arthritis 
Septic arthritis of the sternoclavicular joint (SCJ) is a rare condition and has many diagnostic and therapeutic standards. The purpose of this study was to evaluate our experience with surgical and diagnostic management to provide a surgical pathway to help surgeons treat this disease.
We retrospectively reviewed five patients who were managed surgically between 1999 and 2007. All patients underwent structured diagnostic and treatment protocols. The functional outcome was evaluated using the Constant Score.
The patients had the following underlying medical conditions: laryngeal cancer, port-explantation linked to a rectum carcinoma, spondylodiscitis, and brain stem infarct with reduced general condition; one patient had no underlying medical problems. Three patients underwent a simple incision, debridement and drainage, and two patients underwent an extended intervention with partial resection of the sternoclavicular joint. The mean duration of follow-up was 29 months (range 24–36 months). All patients had well-healed wounds without signs of reinfection. The Constant Score for the functional outcome at the time of the last follow-up was 76 points (range 67–93 points). All patients recovered completely from SCJ disease.
Our recommendations for the management of septic arthritis of the sternoclavicular joint include standard treatment steps and assessments. The early stages of infection can be managed by simple incision, debridement and drainage. In advanced stages of infection, a more radical intervention is preferable.
PMCID: PMC3040322  PMID: 20721567
Septic arthritis; Sternoclavicular joint; Surgical management; Treatment
2.  Paraspinal Abscess Communicated with Epidural Abscess after Extra-Articular Facet Joint Injection 
Yonsei Medical Journal  2007;48(4):711-714.
Facet joint injection is considered to be a safe procedure. There have been some reported cases of facet joint pyogenic infection and also 3 cases of facet joint infection spreading to paraspinal muscle and epidural space due to intra-articular injections. To the author's knowledge, paraspinal and epidural abscesses after facet joint injection without facet joint pyogenic infection have not been reported. Here we report a case in which extra-articular facet joint injection resulted in paraspinal and epidural abscesses without facet joint infection. A 50-year-old man presenting with acute back pain and fever was admitted to the hospital. He had the history of diabetes mellitus and had undergone the extra-articular facet joint injection due to a facet joint syndrome diagnosis at a private clinic 5 days earlier. Physical examination showed tenderness over the paraspinal region. Magnetic resonance image (MRI) demonstrated the paraspinal abscess around the fourth and fifth spinous processes with an additional epidural abscess compressing the thecal sac. The facet joints were preserved. The laboratory results showed a white blood cell count of 14.9 × 109 per liter, an erythrocyte sedimentation rate of 52mm/hour, and 10.88mg/dL of C-reactive protein. Laminectomy and drainage were performed. The pus was found in the paraspinal muscles, which was communicated with the epidural space through a hole in the ligamentum flavum. Cultures grew Staphylococcus aureus. Paraspinal abscess communicated with epidural abscess is a rare complication of extra-articular facet joint injection demonstrating an abscess formation after an invasive procedure near the spine is highly possible.
PMCID: PMC2628056  PMID: 17722247
Complication; infection; injection; facet joint
The Iowa Orthopaedic Journal  2010;30:182-187.
Facet joint septic arthritis is a rare but severe infection with the possibility of significant morbidity resulting from local or systemic spread of the infection. Pain is the most common complaint on presentation followed by fever, then neurologic impairment. While the lumbar spine is involved in the vast majority of cases presented in the literature, the case presented here occurred in the cervical spine. The patient presented with a three week history of neck and left shoulder pain and was diagnosed by MRI when his pain did not respond to analgesics and muscle relaxants. The only predisposing factor was a history of diabetes mellitus and the infection most likely resulted from hematogenous spread. MRI is highly sensitive in diagnosing septic arthritis and it is the preferred modality for demonstrating the extent of infection and secondary complications including epidural and paraspinal abscesses as seen in this case. Without familiarity with this entity's predisposing factors, clinical symptoms and appropriate lab/ imaging work up, many patients experience a delay in diagnosis. Treatment involves long term parenteral antibiotics or percutaneous drainage. Surgical debridement is reserved for cases with severe neurologic impairment. The incidence of facet joint septic arthritis is increasing likely related to patient factors (increasing number of patients >50 yo, immunosuppressed patients, etc), advancement in imaging technology, availability of MRI, and heightened awareness of this rare infection which is the aim of this case presentation.
PMCID: PMC2958294  PMID: 21045995
4.  Bilateral sternoclavicular joint septic arthritis secondary to indwelling central venous catheter: a case report 
Septic arthritis of the sternoclavicular joint is rare, comprising approximately 0.5% to 1% of all joint infections. Predisposing causes include immunocompromising diseases such as diabetes, HIV infection, renal failure and intravenous drug abuse.
Case presentation
We report a rare case of bilateral sternoclavicular joint septic arthritis in an elderly patient secondary to an indwelling right subclavian vein catheter. The insidious nature of the presentation is highlighted. We also review the literature regarding the epidemiology, investigation and methods of treatment of the condition.
SCJ infections are rare, and require a high degree of clinical suspicion. Vague symptoms of neck and shoulder pain may cloud the initial diagnosis, as was the case in our patient. Surgical intervention is often required; however, our patient avoided major intervention and settled with parenteral antibiotics and washout of the joint.
PMCID: PMC2390578  PMID: 18445257
5.  Circular smooth muscle contributes to esophageal shortening during peristalsis 
AIM: To study the angle between the circular smooth muscle (CSM) and longitudinal smooth muscle (LSM) fibers in the distal esophagus.
METHODS: In order to identify possible mechanisms for greater shortening in the distal compared to proximal esophagus during peristalsis, the angles between the LSM and CSM layers were measured in 9 cadavers. The outer longitudinal layer of the muscularis propria was exposed after stripping the outer serosa. The inner circular layer of the muscularis propria was then revealed after dissection of the esophageal mucosa and the underlying muscularis mucosa. Photographs of each specimen were taken with half of the open esophagus folded back showing both the outer longitudinal and inner circular muscle layers. Angles were measured every one cm for 10 cm proximal to the squamocolumnar junction (SCJ) by two independent investigators. Two human esophagi were obtained from organ transplant donors and the angles between the circular and longitudinal smooth muscle layers were measured using micro-computed tomography (micro CT) and Image J software.
RESULTS: All data are presented as mean ± SE. The CSM to LSM angle at the SCJ and 1 cm proximal to SCJ on the autopsy specimens was 69.3 ± 4.62 degrees vs 74.9 ± 3.09 degrees, P = 0.32. The CSM to LSM angle at SCJ were statistically significantly lower than at 2, 3, 4 and 5 cm proximal to the SCJ, 69.3 ± 4.62 degrees vs 82.58 ± 1.34 degrees, 84.04 ± 1.64 degrees, 84.87 ± 1.04 degrees and 83.72 ± 1.42 degrees, P = 0.013, P = 0.008, P = 0.004, P = 0.009 respectively. The CSM to LSM angle at SCJ was also statistically significantly lower than the angles at 6, 7 and 8 cm proximal to the SCJ, 69.3 ± 4.62 degrees vs 80.18 ± 2.09 degrees, 81.81 ± 1.75 degrees and 80.96 ± 2.04 degrees, P = 0.05, P = 0.02, P = 0.03 respectively. The CSM to LSM angle at 1 cm proximal to SCJ was statistically significantly lower than at 3, 4 and 5 cm proximal to the SCJ, 74.94 ± 3.09 degrees vs 84.04 ± 1.64 degrees, 84.87 ± 1.04 degrees and 83.72 ± 1.42 degrees, P = 0.019, P = 0.008, P = 0.02 respectively. At 10 cm above SCJ the angle was 80.06 ± 2.13 degrees which is close to being perpendicular but less than 90 degrees. The CSM to LSM angles measured on virtual dissection of the esophagus and the stomach on micro CT at the SCJ and 1 cm proximal to the SCJ were 48.39 ± 0.72 degrees and 50.81 ± 1.59 degrees. Rather than the angle of the CSM and LSM being perpendicular in the esophagus we found an acute angulation between these two muscle groups throughout the lower 10 cm of the esophagus.
CONCLUSION: The oblique angulation of the CSM may contribute to the significantly greater shortening of distal esophagus when compared to the mid and proximal esophagus during peristalsis.
PMCID: PMC3436046  PMID: 22969194
Esophageal shortening; Gastroesophageal junction; Circular smooth muscle; Gastroesophageal reflux disease; Esophageal contraction
6.  Bilateral Asymmetrical Traumatic Sternoclavicular Joint Dislocations 
Unilateral and bilateral sternoclavicular joint (SCJ) dislocations are rare injuries. The difficulty in assessing this condition often leads to delay in diagnosis and treatment. We report a rare case of bilateral asymmetrical traumatic SCJ dislocations in a 45-year-old male. The right anterior SCJ dislocation was reduced in the emergency room (ER) and resulted in residual instability. The left posterior SCJ dislocation was asymptomatic and unnoticed for six months. It is important for ER physicians and orthopaedic surgeons to be able identify and treat this condition. All suspected SCJ dislocations should be evaluated by computed tomography (CT) scan for confirmation of the diagnosis and evaluation of both SCJs. Posterior SCJ dislocation is a potentially fatal injury and should not be overlooked due to the presence of other injuries. Surgical intervention is often necessary in acute and old cases.
PMCID: PMC3524004  PMID: 23275851
Shoulder; Sternoclavicular joint; Dislocations; Emergency; Case report; Saudi Arabia
7.  Sternoclavicular Joint Infection: Classification of Resection Defects and Reconstructive Algorithm 
Archives of Plastic Surgery  2012;39(6):643-648.
Aggressive treatment of sternoclavicular joint (SCJ) infection involves systemic antibiotics, surgical drainage and resection if indicated. The purpose of this paper is to describe a classification of post resectional SCJ defects and highlight our reconstructive algorithm. Defects were classified into A, where closure was possible often with the aid of topical negative pressure dressing; B, where parts of the manubrium, calvicular head, and first rib were excised; and C, where both clavicular, first ribs and most of the manubrium were resected.
Twelve patients (age range, 42 to 72 years) over the last 8 years underwent reconstruction after SCJ infection. There was 1 case of a type A defect, 10 type B defects, and 1 type C defect. Reconstruction was performed using the pectoralis major flap in 6 cases (50%), the latissimus dorsi flap in 4 cases (33%), secondary closure in 1 case and; the latissimus and the rectus flap in 1 case.
All wounds healed uneventfully with no flap failure. Nine patients had good shoulder motion. Three patients with extensive clavicular resection had restricted shoulder abduction and were unable to abduct their arm past 90°. Internal and external rotation were not affected.
We highlight our reconstructive algorithm which is summarised as follows: for an isolated type B SCJ defect we recommend the ipsilateral pectoralis major muscle for closure. For a type C bilateral defect, we suggest the latissimum dorsi flap. In cases of extensive infection where the thoracoacromial and internal mammary vessels are thrombosed, the pectoralis major and rectus abdominus cannot be used; and the latissimus dorsi flap is chosen.
PMCID: PMC3518009  PMID: 23233891
Sternoclavicular joint; Infectious arthritis; Surgical flap
8.  Cervical squamocolumnar junction-specific markers define distinct, clinically relevant subsets of low-grade squamous intraepithelial lesions 
Low grade cervical squamous abnormalities [low grade squamous intraepithelial lesions (LSIL, CIN1)] can be confused with or followed by high grade (HSIL, CIN2/3) lesions, expending considerable resources. Recently, a cell of origin for cervical neoplasia was proposed in the squamocolumnar junction (SCJ); HSILs are almost always SCJ marker-positive (+) but LSILs include SCJ+ and negative (−) subsets. Abnormal cervical biopsies from 214 patients were classified by two experienced pathologists ("panel") as LSIL or HSIL using published criteria. SILs were scored SCJ+ and SCJ- using SCJ-specific antibodies (Keratin7, AGR2, MMP7 and GDA). Assessments of interobserver agreement, p16ink4 staining pattern, proliferative index and outcome were compared. The original diagnostician agreed with the panel diagnosis of HSIL and SCJ- LSIL in all cases (100%). However for SCJ+ LSIL, panelists disagreed with each other on 15% and with the original diagnostician on 46.2%. Comparing SCJ- and SCJ+ LSILs, 60.2% and 94.9% scored p16ink4 positive, 23% and 74.4% showed strong (full-thickness) p16ink4 staining, and 0/54 (0%) and 8/33 (24.2%) with follow-up had an HSIL outcome respectively. Some SCJ+ LSILs are more likely to both generate diagnostic disagreement and be associated with HSIL. Conversely, SCJ- LSILs generate little observer disagreement and when followed, have a very low risk of HSIL outcome. Thus, SCJ biomarkers in conjunction with histology may segregate LSILs with very low risk of HSIL outcome and conceivably could be used as a management tool to reduce excess allocation of resources to the followup of these lesions.
PMCID: PMC3905241  PMID: 24076771
9.  Septic arthritis of unilateral lumbar facet joint with contiguous abscess, without prior intervention 
BMJ Case Reports  2012;2012:bcr0920114849.
A 40-year-old female patient presented with persistent severe back pain radiating to the right leg, abdominal pain and constipation. Other clinical symptoms included nausea, vomiting and high-grade fever. Clinical examination showed generalised abdominal and lower back tenderness. There was no sensory loss or motor weakness in lower limbs, however investigations showed raised inflammatory markers. Radiographs of the lumbar spine and hip joint were normal. MRI revealed a septic arthritis of the right L3/4 facet joint, associated with a large abscess extending anteriorly to the right paraspinal muscles and posteriorly into the right posterolateral aspect of the epidural space in the central spinal canal, with moderate compression of the dural sac. Unlike any other reported similar case, this septic arthritis developed without prior medical intervention. The patient was treated successfully with ultrasound guided drainage of the facet joint/abscess and antibiotics.
PMCID: PMC3339176  PMID: 22602829
10.  Microperforation prolotherapy: a novel method for successful nonsurgical treatment of atraumatic spontaneous anterior sternoclavicular subluxation, with an illustrative case 
Surgical repair of an atraumatic spontaneous anterior subluxation of the sternoclavicular joint (herein referred to as the “SCJ”) is often associated with poor outcome expectations. With traditional treatment, successful conservative therapy usually incorporates major lifestyle alterations. This manuscript discusses a novel approach known as “microperforation prolotherapy”. To illustrate the technique, the care of a patient who benefitted from this treatment is reviewed.
To present a novel form of treatment with an illustrative case that demonstrates the potential efficacy of microperforation prolotherapy of the SCJ.
Patient and methods
A novel approach to treatment of bilateral subluxation of the sternoclavicular joint with microperforation prolotherapy is discussed. The clinical course of a 21-year-old male with bilateral subluxation of the SCJ, which seriously hampered the patient’s athletic and daily living activities, is used as a backdrop to the discussion.
Following microperforation prolotherapy, the instability of the SCJ was replaced by full stability, complete range of motion, and the opportunity to engage in all of the athletic endeavors previously pursued. There is no scar or other cosmetic defect resulting from the treatment received.
Anterior sternoclavicular joint subluxation has a poor record of complete recovery with surgical procedures or conservative measures with regard to providing restoration of full lifestyle function. This manuscript documents a novel microperforation prolotherapy treatment that induced healing and restored full stability to the ligament structures responsible for the condition in a completely safe and effective fashion, allowing the patient to resume full lifestyle activities without restriction. The exceptional response to treatment noted here is encouragement for further studies.
PMCID: PMC3781882  PMID: 24198570
sternoclavicular joint subluxation; shoulder pain; sternoclavicular instability; spontaneous instability; anterior subluxation
11.  Septic arthritis of the temporomandibular joint: Case reports and review of the literature 
The Journal of emergency medicine  2013;45(5):674-678.
Septic arthritis of the temporomandibular (TM) joint is rare, but it is associated with high risk for significant morbidity.
We reviewed the available literature regarding the presentation, evaluation, treatment, and clinical course of TM joint septic arthritis, focusing on elements relevant to emergency medicine physicians.
Case Reports
In the first case, a healthy 6-year-old boy presented with fever and trismus; computed tomography with contrast revealed a TM joint effusion. After empiric intravenous antibiotics, intraoperative arthrocentesis of the TM joint returned one milliliter of flocculent fluid, which was cultured and grew pan-sensitive Streptococcus pyogenes. He was discharge home with amoxicillin/clavulanate and experienced complete resolution of his symptoms. In the second case, more than three weeks after extraction of her third molars, an 18-year-old woman presented with facial pain, swelling, and trismus and was found to have a loculated abscess involving the left masseteric and pterygomandibular spaces with extension to the left deep temporal region and the skull base. She experienced a complicated postoperative course and required multiple procedures and intravenous antibiotics for growth of multiple bacteria. More than a month later underwent TM joint arthrotomy for TM joint septic arthritis, and she was found to have acute osteomyelitis. She continued to require multiple treatment modalities; twenty months after her initial presentation, she underwent left total TM joint arthroplasty for fibrous ankylosis of the TM joint.
Septic arthritis of the TM joint may be caused by hematogenous spread of distant infection or local spread of deep masticator space infections. Patients may present with TM joint septic arthritis acutely or sub-acutely. Septic arthritis of the TM joint should be considered in the differential diagnosis of patients who present with trismus and pain or fever.
PMCID: PMC4074402  PMID: 23896057
septic arthritis; temporomandibular joint; emergency department (ED); pediatric; adult; trismus
12.  Spinal Epidural Abscess with Pyogenic Arthritis of Facet Joint Treated with Antibiotic-Bone Cement Beads - A Case Report - 
Asian Spine Journal  2007;1(1):61-64.
Most epidural abscesses are a secondary lesion of pyogenic spondylodiscitis. An epidural abscess associated with pyogenic arthritis of the facet joint is quite rare. To the best of our knowledge, there is no report of the use of antibiotic-cement beads in the surgical treatment of an epidural abscess. This paper reports a 63-year-old male who sustained a 1-week history of radiating pain to both lower extremities combined with lower back pain. MRI revealed space-occupying lesions, which were located in both sides of the anterior epidural space of L4, and CT scans showed irregular widening and bony erosion of the facet joints of L4-5. A staphylococcal infection was identified after a posterior decompression and an open drainage. Antibiotic- bone cement beads were used as a local controller of the infection and as a spacer or an indicator for the second operation. An intravenous injection of anti-staphylococcal antibiotics resolved the back pain and radicular pain and normalized the laboratory findings. We point out not only the association of an epidural abscess with facet joint infection, but also the possible indication of antibiotic-bone cement beads in the treatment of epidural abscesses.
PMCID: PMC2857502  PMID: 20411156
Epidural abscess; Facet joint infection; Lumbar spine; Antibiotic-bone cement bead
13.  Minimally Invasive Approach for Drainage of a Sacral Epidural Abscess 
Interventional Neuroradiology  2007;13(2):161-165.
Sacral epidural abscesses are rare infections, often managed with open surgery, especially in the presence of acute neurological symptoms. We report a novel approach for minimally invasive drainage of sacral epidural abscesses.
A 51-year-old man presented to the emergency department complaining of low back pain, generalized muscle pain, pain across several large joints, low-grade fever, and weakness of both legs for ten days. MRI of the patient's lumbosacral spine showed osteomyelitis involving his L5, S1 vertebrae, L5-S1 discitis, as well as anterior and posterior epidural abscesses extending from L5-S1 disc space to the S2 vertebral level. Under CT fluoroscopic guidance a 20-gauge spinal needle was inserted into the sacral hiatus, parallel to the pelvic surface of the sacral canal, and directed cranially. A 0.18-gauge microwire was then advanced through the 20-gauge needle. The 20-gauge needle was exchanged over the guidewire for an 18-gauge blunt tipped needle which was curved to approximate the contours of the sacral canal. The curved needle was inserted through the sacral hiatus with its concavity initially facing upwards, and then rotated 180° to gain access to epidural abscess.
Once anatomic access was established 5cc of thick purulent material was evacuated. The patient tolerated the procedure well, and no focal nerve root symptoms were noted following the procedure.
Image guided aspiration of sacral epidural abscesses can be carried out in a safe and effective manner using CT fluoroscopy. Aspiration of these abscesses combined with intravenous antibiotics may be an alternative to open surgery in select patients.
PMCID: PMC3345478  PMID: 20566144
sacral abscess, osteomielitis, spine, percutaneous drainage
14.  Septic hematogenous lumbar spondylodiscitis in elderly patients with multiple risk factors: efficacy of posterior stabilization and interbody fusion with iliac crest bone graft 
European Spine Journal  2010;19(10):1720-1727.
The conservative and operative treatment strategies of hematogenous spondylodiscitis in septic patients with multiple risk factors are controversial. The present series demonstrates the outcome of 18 elderly patients (median age, 72 years) with septic hematogenous spondylodiscitis and intraspinal abscess treated with microsurgical decompression and debridement of the infective tissue, followed by posterior stabilization and interbody fusion with iliac crest bone graft in one or two lumbar segments. The majority of the patients were unsuccessfully treated with intravenous antibiotics prior to the operation. Antibiotic therapy was continued for more than 6 weeks postoperatively. Morbidity and early mortality amounted to 50 and 17%, respectively. Three patients died in the hospital from internal complications after an initial postoperative improvement of the inflammatory clinical signs and laboratory parameters. Fifteen patients recovered from the spinal infection. Three of them died several months after discharge (cerebral hemorrhage, malignancy and unknown cause). Twelve patients had excellent or good outcomes during the follow-up period of at least 1 year. The series shows that operative decompression and eradication of the intraspinal and intervertebral infective tissue with fusion and stabilization via a posterior approach is possible in septic patients with multiple risk factors and leads to good results in those patients, who survive the initial severe stage of the septic disease. However, the morbidity and mortality suggest that this surgical treatment is not the therapy of first choice in high-risk septic patients, but may be considered in patients when conservative management has failed.
PMCID: PMC2989220  PMID: 20495933
Spondylodiscitis; Posterior lumbar interbody fusion; Sepsis; Spinal epidural abscess; Elderly patients
15.  Retrosternal abscess after trigger point injections in a pregnant woman: a case report 
Although retrosternal abscess is a well known complication of sternotomy and intravenous drug abuse, to date it has not been described as a consequence of trigger point injections. There are reported cases of serious complications as a result of this procedure including epidural abscess, necrotizing fasciitis, osteomyelitis and gas gangrene.
Case presentation
A 37-year-old African-American woman, who was 20 weeks pregnant, presented to our emergency room with complaints of progressively worsening chest pain and shortness of breath over the course of the last two months. She was undergoing trigger point injections at multiple different sites including the sternoclavicular joint for chest pain and dystonia. Two years previously she had developed a left-sided pneumothorax as a result of this procedure, requiring chest tube placement and subsequent pleurodesis. Her vital signs in our emergency room were normal except for resting tachycardia, with a pulse of 100 beats per minute. A physical examination revealed swelling and tenderness of the sternal notch with tenderness to palpation over the left sternoclavicular joint. Laboratory data was significant for a white blood count of 13.3 × 109/L with 82% granulocytes. A chest radiograph revealed left basilar scarring with blunting of the left costophrenic angle. A computed tomography angiogram showed a 4.7 cm abscess in the retrosternal region behind the manubrium with associated sclerosis and cortical irregularity of the manubrium and left clavicle.
Trigger point injection is generally considered very safe. However, there are reported cases of serious complications as a result of this procedure. A computed tomography scan of the chest should strongly be considered in the evaluation of chest pain and shortness of breath of unclear etiology in patients with even a remote history of trigger point injections.
PMCID: PMC3174928  PMID: 21859491
16.  Community-Acquired MRSA Pyomyositis: Case Report and Review of the Literature 
Journal of Tropical Medicine  2011;2011:970848.
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is responsible for a broad range of infections. We report the case of a 46-year-old gentleman with a history of untreated, uncomplicated Hepatitis C who presented with a 2-month history of back pain and was found to have abscesses in his psoas and right paraspinal muscles with subsequent lumbar spine osteomyelitis. Despite drainage and appropriate antibiotic management the patient's clinical condition deteriorated and he developed new upper extremity weakness and sensory deficits on physical exam. Repeat imaging showed new, severe compression of the spinal cord and cauda equina from C1 to the sacrum by a spinal epidural abscess. After surgical intervention and continued medical therapy, the patient recovered completely. This case illustrates a case of CA-MRSA pyomyositis that progressed to lumbar osteomyelitis and a spinal epidural abscess extending the entire length of the spinal canal.
PMCID: PMC3065056  PMID: 21461362
Prevention of complications is one of the most important aspects of patient care in pain management. The objective of this study is to review documented complications in medical literature that are associated with interventional pain management, specifically those associated with joint, tendon, and muscle injections. We conducted Medline research from 1966 to November 2006 using keywords complication, injection, radiofrequency, closed claim, facet, zygophyseal joint, sacroiliac joint, shoulder, hip, knee, carpel tunnel, bursa, and trigger point. We found over 35 relevant papers in forms of original articles, case reports, and reviews. The most common complications appear to be infections that have been associated with virtually all of these injections. These infections include spondylodiscitis, septic arthritis, epidural abscess, necrotizing fasciitis, osteomyelitis, gas gangrene, and albicans arthritis. Other complications include spinal cord injury and peripheral nerve injuries, pneumothorax, air embolism, pain or swelling at the site of injection, chemical meningism, granulomatous inflammation of the synovium, aseptic acute arthritis, embolia cutis medicamentosa, skeletal muscle toxicity, and tendon and fascial ruptures. We suggest that many of the infectious complications may be preventable by strict adherence to aseptic techniques and that some of the other complications may be minimized by refining the procedural techniques with a clear understanding of the relevant anatomies.
PMCID: PMC2084363  PMID: 18591992
18.  Minimally invasive endoscopic treatment for lumbar infectious spondylitis: a retrospective study in a tertiary referral center 
Spinal infections remain a challenge for clinicians because of their variable presentation and complicated course. Common management approaches include conservative administration of antibiotics or aggressive surgical debridement. The purpose of this study was to evaluate the efficacy of percutaneous endoscopic debridement with dilute betadine solution irrigation (PEDI) for treating patients with lumbar infectious spondylitis.
From January 2005 to July 2010, a total of 32 patients undergoing PEDI were retrospectively enrolled in this study. The surgical indications of the enrolled patients included single-level infectious spondylodiscitis, postoperative infectious spondylodiscitis, advanced infection with epidural abscess, psoas muscle abscess, pre-vertebral or para-vertebral abscess, multilevel infectious spondylitis, and recurrent infection after anterior debridement and fusion. Clinical outcomes were assessed by careful physical examination, Macnab criteria, regular serologic testing, and imaging studies to determine whether continued antibiotics treatment or surgical intervention was required.
Causative bacteria were identified in 28 (87.5%) of 32 biopsy specimens. Appropriate parenteral antibiotics for the predominant pathogen isolated from infected tissue biopsy cultures were prescribed to patients. Twenty-seven (84.4%) patients reported satisfactory relief of their back pain after PEDI. Twenty-six (81.3%) patients recovered uneventfully after PEDI and sequential antibiotic therapy. No surgery-related major complications were found, except 3 patients with transient paresthesia in the affected lumbar segment.
PEDI was successful in obtaining a bacteriologic diagnosis, relieving the patient’s symptoms, and assisting in the eradication of lumbar infectious spondylitis. This procedure could be an effective alternative for patients who have a poor response to conservative treatment before a major open surgery.
PMCID: PMC3986884  PMID: 24669940
Betadine; Endoscopic debridement; Infectious spondylitis; Minimally invasive surgery
19.  Arthritis of the sternoclavicular joint masquerading as rupture of the cervical oesophagus: a case report 
Sternoclavicular septic arthritis is a rare condition and accounts only for 1% of cases of septic arthritis in the general population. The most common risk factors are intravenous drug use, central-line infection, distant-site infection, immunosuppression, trauma and diabetes mellitus. This is a report of an unusual case where this type of arthritis was masquerading as rupture of the cervical oesophagus.
Case presentation
A 63-year-old man presented complaining of right neck pain and dysphagia following a bout of violent coughing. Physical examination revealed cellulitis extending from the right sternoclidomastoid region to the anterior upper chest. Computed tomography showed inflammatory changes behind the right sternoclavicular joint with mediastinitis and ipsilateral pleural effusion. These findings raised the suspicion of spontaneous rupture of the cervical oesophagus. Management involved jejunal feeding along with broad-spectrum antibiotics. The inflammation, however, relapsed after discontinuation of the antibiotics and this time, computed tomography pointed to a diagnosis of arthritis of the sternoclavicular joint. The patient responded completely to a 6-week course of oral penicillin, flucloxacillin and metronidazole.
Sternoclavicular arthritis is a rare condition that has been associated with a variety of predisposing factors. It may, however, occur in otherwise completely healthy individuals and should be included in the differential diagnosis of other inflammatory conditions of the neck and upper chest.
PMCID: PMC2639601  PMID: 19178739
20.  Escherichia coli – Marauding masquerading microbe 
Escherichia coli is a rare cause of monoarticular septic arthritis, but is an even rarer cause of polyarticular septic arthritis.
Case description
We report an unusual case of polyarticular septic arthritis with an atypical presentation caused by E. coli, the source of which was a left pyelonephritis. Our patient developed E coli sepsis resulting in polyarticular septic arthritis (PASA) in the absence of typical risk factors except for pre-existing osteoarthritis. The joints involved were the hip, ankle, sternoclavicular and L5/S1 joints. Of interest, ankle pain was not reported or evident until correlated with nuclear medicine scans. Furthermore, sternoclavicular joint involvement presented as left shoulder pain, resulting in an initial misdiagnosis of left shoulder septic arthritis. The patient was treated with surgical washout and antibiotic therapy. He was subsequently discharged from rehabilitation having returned to his baseline level of mobility. Future consideration will be given to total hip arthroplasty.
Literature review
There are no reported cases of E. coli PASA involving more than three joints in the absence of any recognized risk factors for septic arthritis.
Purpose and clinical relevance
Asymptomatic involvement of joints can occur in polyarticular septic arthritis and should be considered in all cases of monoarticular septic arthritis (MASA). We believe that clinical suspicion is the key to early and comprehensive diagnosis of polyarticular septic arthritis particularly when presenting in an atypical fashion with an atypical pathogen. Strong consideration should be given to performing nuclear imaging in cases of monoarticular septic arthritis where polyarticular involvement cannot be definitively ruled out.
PMCID: PMC3880952
Escherichia coli sepsis; Polyarticular septic arthritis; Septic arthritis; Nuclear medicine imaging; Bone-Gallium scan
21.  Percutaneous transpedicular discectomy and drainage in pyogenic spondylodiscitis 
European Spine Journal  2004;13(8):707-713.
The natural history of uncomplicated hematogenous pyogenic spondylodiscitis is self-limiting healing. However, a variable degree of bone destruction frequently occurs, predisposing the spine to painful kyphosis. Delayed treatment may result in serious neurologic complications. Early debridement of these infections by percutaneous transpedicular discectomy can accelerate the natural process of healing and prevent progression to bone destruction and epidural abscess. The purpose of this manuscript is to present our technique of percutaneous transpedicular discectomy (PTD), to revisit this minimally invasive surgical technique with stricter patient selection, and to exclude cases of extensive vertebral body destruction with kyphosis and neurocompression by epidural abscess, infected disc herniation, and foraminal stenosis. In a previously published report of 28 unselected patients with primary hematogenous pyogenic spondylodiscitis, the immediate relief of pain after PTD was 75%, and in the longterm follow-up, the success rate was 68%. Applying stricter patient selection criteria in a second series of six patients (five with primary hematogenous spondylodiscitis and one with secondary postlaminectomydiscectomy spondylodiscitis), all patients with primary hematogenous spondylodiskitis (5/5) experienced immediate relief of pain that remained sustained at 12–18 months follow-up. This procedure was not very effective, however, in the patient who suffered from postlaminectomy infection. This lack of response was attributed to postlaminectomydiscitis instability. The immediate success rate after surgery for unselected patients in this combined series of 34 patients was 76%. This technique can be impressively effective and the results sustained when applied in the early stages of uncomplicated spondylodiscitis and contraindicated in the presence of instability, kyphosis from bone destruction, and neurological deficit. The special point of this procedure is a minimally invasive technique with high diagnostic and therapeutic effectiveness.
PMCID: PMC3454057  PMID: 15197626
Percutaneous transpedicular discectomy; Primary hematogenous pyogenic spondylodiscitis
22.  Chronic spinal subdural abscess mimicking an intradural–extramedullary tumor 
European Spine Journal  2013;22(Suppl 3):497-500.
Spinal subdural abscesses (SSA) are very rare disease. The etiologies of SSA are hematogenous spread, iatrogenic contamination, and local extension. Elevated WBC counts, ESR, and C-reactive protein are usually found in laboratory tests. But they are not sensitive indicators of SSA, especially chronic abscesses patient tend to have a less specific characteristic. We report the case of a healthy man with chronic subdural abscess referred to our hospital as an intradural–extramedullary (IDEM) tumor. The patient presented with voiding difficulty and pain in the back and left leg. In a contrast MRI scan, a rim-enhanced mass-like lesion was seen at the L5/S1 level. But adjacent ill-defined epidural fat enhancement that are unusual imaging manifestation for IDEM tumors was seen. He had no fever and normal WBC, ESR, and CRP. In addition, the patient had no previous infection history or other disease, but he did have an epidural block for back pain at another hospital 2 years previously. So, we repeated the MRI with a high-resolution 3-T scanner. The newly taken MR images in our hospital revealed a clear enlargement of lesion size compared to the previous MRI taken 1 week before in other hospital. We suspected a chronic spinal subdural abscess with recent aggravation and immediately performed surgical evacuation. In the surgical field, tensed dura was observed and pus was identified after opening the abscess capsule. Because chronic spinal subdural abscesses are difficult to diagnose, we could differentiate with IDEM tumor exactly and an exact history taking, contrast MRI are required.
PMCID: PMC3641243  PMID: 23397217
Spinal subdural abscess; Chronic spinal subdural abscess; Intradural–extramedullary tumor; Spinal cord tumor
23.  Diagnostic difficulties resulting from morphological image variation in spondylodiscitis MR imaging 
Polish Journal of Radiology  2012;77(3):25-34.
Spinal infection (discitis; spondylodiscitis) presents a wide spectrum of pathologies. The method of choice for spondylodiscitis imaging is magnetic resonance (MR). It provides detailed anatomical information, especially concerning epidural space and spinal cord. The main aim of this article is the description and evaluation of spondylodiscitis morphological variation visible in magnetic resonance imaging.
In this article we retrospectively analysed the patients diagnosed at the Department of Radiology of the Provincial Hospital No 2 in Rzeszów between October 2009 and October 2011. The subjects involved a group of five women aged 41–74 (mean 56.3 years) and eight men aged 46–69 (mean 61,3 years). All patients had spondylodiscitis symptoms. All patients underwent MRI examination before and after the contrast enhancement. In three patients additional CT examination was performed.
Following the MRI procedure all patients were diagnosed with typical symptoms of spondylodiscitis. It also revealed a number of pathologies resulting from morphological spondylodiscitis variation. Other pathologies found on the MR images of the study group patients involved epidural intra-canal spinal pathological masses causing spinal cord compression, lung abscess, pyothorax, paravertebral abscesses and epidural empyemas, abscess between adjacent vertebral bodies, abscesses beneath anterior longitudinal ligament, and iliopsoas muscle abscesses. In all cases a destruction of vertebral bodies with end plates loss restriction and cortical layer discontinuity was observed. Moreover, one person was diagnosed with pathological vertebral body fractures and liquefactive necrosis of the vertebral body.
Spondylodiscitis manifests itself in a great number of morphological variations visible on the radiological images. Apart from ordinary features of vertebral bodies and discs, progressive spinal destruction is observed together with reactive bone changes and soft tissue infiltration. The latter leads to a number of complications e.g. abscesses or even fistulas and also to the formation of obstacles in radiological images. The knowledge of radiological images together with overall evaluation of clinical and laboratory features enables a proper diagnosis.
PMCID: PMC3447430  PMID: 23049578
spondylodiscitis; discitis; discovertebral junction
24.  Fatal outcome after insufficient spine fixation for pyogenic thoracic spondylodiscitis: an imperative for 360° fusion of the infected spine 
Pyogenic spondylodiscitis represents a potentially life-threatening condition. Due to the low incidence, evidence-based surgical recommendations in the literature are equivocal, and the treatment modalities remain controversial.
Case presentation
A 59 year-old patient presented with a history of thoracic spondylodiscitis resistant to antibiotic treatment for 6 weeks, progressive severe back pain, and a new onset of bilateral lower extremity weakness. Clinically, the patient showed a deteriorating spastic paraparesis of her lower extremities. An emergent MRI revealed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression, paravertebral and epidural abscess, and signs of myelopathy. The patient underwent surgical debridement with stabilization of the anterior column from T6–T9 using an expandable titanium cage, autologous bone graft, and an anterolateral locking plate. The patient recovered well under adjunctive antibiotic treatment. She presented again to the emergency department 6 months later, secondary to a repeat fall, with acute paraplegia of the lower extremities and radiographic evidence of failure of fixation of the anterior T-spine. She underwent antero-posterior revision fixation with hardware removal, correction of kyphotic malunion, evacuation of a recurrent epidural abscess, decompression of the spinal canal, and 360° fusion from T2–T11. Despite the successful salvage procedure, the patient deteriorated in the postoperative phase, when she developed multiple complications including pneumonia, acute respiratory distress syndrome, bacterial meningitis, abdominal compartment syndrome, followed by septic shock with multiple organ failure and a lethal outcome within two weeks after revision surgery.
This catastrophic example of a lethal outcome secondary to failure of anterior column fixation for pyogenic thoracic spondylodiscitis underlines the notion that surgical strategies for the infected spine must be aimed at achieving absolute stability by a 360° fusion. This aggressive – albeit controversial – concept allows for an adequate infection control by adjunctive antibiotics and reduces the imminent risk of a secondary loss of fixation due to compromises in initial fixation techniques.
PMCID: PMC2654872  PMID: 19243602
25.  Spinal epidural abscess following blunt pelvic trauma 
European Spine Journal  2000;9(1):80-84.
A 17-year-old patient with pre-existing grade II spondylolisthesis of L5/S1 sustained a partial disruption of the left sacroiliac joint with haematoma of the iliac muscle after a fall. The haematoma probably led to occlusion of the left ureter, resulting in a urinary tract infection. After initial conservative treatment the patient developed fever and radicular pain of the left leg. Magnetic resonance imaging (MRI) revealed a left-sided epidural abscess at L5/S1, which had probably spread from the infected iliac haematoma along the injured sacroiliac joint. Prompt surgical drainage and antibiotic coverage with cefuroxime and flucloxacillin led to rapid clinical improvement. Staphylococcus aureus was identified as the pathogen. At follow-up 6 months postoperatively all symptoms had resolved, while MRI still revealed residual osseous oedema of the sacroiliac joint. The haematoma of the iliac muscle resolved without surgical intervention.
PMCID: PMC3611346  PMID: 10766083
Key words Epidural abscess; Pelvic trauma; Complication; Urinary tract infection

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