ABSTRACT
History: A 20 year old D1 men's basketball player with a history of COVID the month prior presented with worsening low back pain. He denied any injury, but reported the pain started as low back discomfort after a basketball game the week prior. He noted a progression and radiation of pain down his right lower extremity to his toes. He had tried physical therapy and dry needling, as well as cyclobenzaprine and naproxen from team physicians with mild improvement. The pain worsened and he went to the ED for evaluation. He was afebrile and had a lumbar radiograph with no acute fracture, grade 1 anterolisthesis of L5 on S1. He was discharged home with norco. Over the next 2 days, he developed chills and in the context of his worsening back pain, his team physicians ordered an MRI. Physical Exam: BMI 26.9 Temp 97.9degree Heart rate: 73 Respiratory rate 14 BP: 124/64 MSK: Spine- Intact skin with generalized pain over lumbar area, worse over the right paraspinal musculature. 5/5 strength of bilateral lower extremity flexion and extension of his hips, knees, and plantar and dorsiflexion of ankles and toes. Bilateral intact sensibility in the sciatic, femoral, superficial, and deep peroneal, sural, and saphenous nerve distributions. Slightly diminished sensibility over the right deep peroneal nerve distribution compared to left. 2/4 patellar and achilles DTRs. No clonus, downgoing Babinski sign. Positive straight leg raise at 45 degrees with the right lower extremity. Differential Diagnosis: 141. Sciatica 142. Lumbar Muscle Strain 143. Disk Herniation 144. Spondylolisthesis 145. Vertebral Osteomyelitis Test Results: CBC:WBC10, HGB13.2, neutrophils 75.7% (red 45%-74%). Unremarkable CMP. CRP =7.31, ESR 23 Blood culture negative, throat culture negative. TB test negative. COVID test negative. Flu test negative. Urine culture and UDS negative. HIV test negative. Procalcitonin of 0.07. IR guided aspiration and bacterial Culture yielded MSSA. MRI w/contrast: showing L1-L4 facet edema concerning for infectious spondylitis, intramuscular, and epidural abscess. Final Diagnosis: Acute intramuscular abscess, vertebral osteomyelitis, with epidural abscess. Discussion(s): Vertebral osteomyelitis is a serious but quite rare disease in the immunocompetent, elite athlete population. Staphylococcus Aureus is the culprit a majority of the time, with only 50% of cases showing neurologic symptoms. This case was unique given the proximity to a dry needling treatment which is the only explainable vector of infection, normal blood cultures in this disease which hematogenously spreads, negativeHIV and other infectious disease testing, and otherwise benign history. Early recognition of this disease yields better outcomes and reduces incidence of severe debility. 5% to 10%of patients experience recurrence of back pain or osteomyelitis later on in life. Outcome(s): Patient was hospitalized and started on Cefepime and Vancomycin. Had an echocardiogram revealing changes consistent with athlete's heart without signs of vegetation on his cardiac valves. Neurosurgery declined to treat surgically. He continued to improve until he was ultimately discharged on hospital day 4 with a picc line and Nafcillin and was later changed to oral augmentin per ID. Follow-Up: By his 6 week follow-up visit with infectious disease and the team physicians, his back pain had completely resolved and was cleared to start a return to play protocol. There was no progression of disease since starting antibiotics, and no recurrence of back pain since treatment.
ABSTRACT
Background: Hospitals are one of the primary resources for disease transmission, so many guidelines were published, and neuro-surgeons were advised to postpone elective spine surgeries during the COVID-19 pandemic. Objective(s): To avoid pulmonary complications and reduce the risk of spreading the virus and contracting the disease during the COVID-19 era, we operated a group of our patients under spinal anesthesia rather than general anesthesia. Method(s): We retrospectively analyzed all patients who underwent discectomy surgery for lumbar spinal disc herniation under SA between September 2020 and 2021. Result(s): Sixty-four patients diagnosed with lumbar disc herniation underwent lumbar discectomy with SA. All patients except three were male. The mean age was 44.52 +/- 7.95 years (28 to 64 years). The mean procedure time for SA was 10 minutes. The duration of the surgery was 40 to 90 minutes per each level of disc herniation. The mean blood loss was 350 cc (200 to 600 cc). The most common involved level was L4/L5 intervertebral disc (n = 40 patients;63.5%). The mean recovery time was 20 minutes. Only three patients requested more analgesics for relief of their pain postoperatively. All patients with discectomy were discharged a day after surgery, and in the case of fusion, two days after surgery. All the patients were followed up for six months, showing no recurrence symptoms, good pain relief, satisfaction with the surgery, and no bad memory of the surgery. Conclusion(s): Spinal anesthesia is a good alternative or even the main anesthesia route for patients with lumbar disc herniation. More studies are needed to elucidate the best candidate for SA in patients with lumbar pathology.Copyright © 2023, Author(s).
ABSTRACT
Introduction: The Covid-19 pandemic has negatively impacted the management of spinal pathologies. Since, so far, the pandemic's effects specifically on the management of myelopathy in Germany have not been examined, we aim to do so in this analysis. Method(s): We used administrative data from a nationwide Network of 76 hospitals for this retrospective analysis and compared the first 5 pandemic waves (Jan 1, 2020 - May 17, 2022) to corresponding periods from the last year prior to the pandemic (2019). We included all patients hospitalized with the main diagnosis "myelopathy" (ICD-10-Codes: M47.11-15, G95.2, G99.2) and examined baseline characteristics and rates of different treatment types and in-hospital mortality. Result(s): We included 4,167 cases with myelopathy: 2,001 hospitalized during the pandemic, and 2,166 in 2019. Compared to pre-pandemic levels, the mean daily admissions for myelopathy decreased only in wave 1 (from 2.8 auf 1.7;p<0.01), while no changes in admissions were registered in any of the later waves. There were no alterations in patient age (range: 64.5-66.1 years), distribution of sex (female, range: 39.3%-50.4%), or rates of comorbidities, measured by the Elixhauser Comorbidity Index (range: 4.3-6.5). In contrast, we observed significant changes in the analysis of treatment modalities. Except in wave 1, there was a significant increase in rates of spinal decompression procedures throughout the pandemic, from a range of 43.3-47.0% before the pandemic to 55.6%-62.5% (p<0.01). Also, compared to prepandemic levels, the rates of disc hernia resections increased during waves 4 and 5 from a range of 29.8-30.4% to 37.1-41.1% (p<0.01). Furthermore, the rates of spinal fusion procedures increased in waves 3, 4, and 5 from a range of 32.7-40.5% to 45.0- 50.4% (p<0.01). No changes were observed throughout the pandemic for rates of kyphoplasty (0.2-1.0%), transfer to intensive care unit (22.9-30.7%), and in-hospital mortality (1.1-2.7%). Discussion(s): We present the largest analysis, to date, on the effects of the COVID-19 pandemic on the management of myelopathy in Germany. Our findings suggest that, in subjects with myelopathy, the pandemic did not lead to a selection for older or sicker patients. The fact that hospital admissions for myelopathy dropped off only during the wave 1 suggests a certain normalization over time. This is why it is worth discussing why rates of surgery increased in later phases of the pandemic, both for fusion and non-fusion procedures.
ABSTRACT
Introduction: In patients with degenerative spinal disease, higher degrees of fraily, as measured by the Hospital Frailty Risk Score (HFRS), are associated with poor treatment outcomes. The COVID-19 pandemic has led to significant increases in frailty among hospitalized patients. We present the first nationwide analysis of the impact the COVID-19 pandemic has been having on frailty among spine patients. Method(s): In this retrospective study we examined administrative data from a nationwide network of 76 hospitals in Germany with emphasis on HFRS, types of treatment and outcomes. We compared data from the last year prior to the pandemic (2019) to the first 5 waves of the pandemic (Jan 1, 2020 - May 17, 2022). All patients with a primary diagnosis of degenerative, traumatic or infectious spinal disease were included. The following HFRS groups were compared to each other: low (< 5 points), intermediate (5-15 points), and high (>15 points). Result(s): Of the 379,910 included cases with spine pathologies 168,481 were hospitalized during the pandemic, and 194,722 in 2019. Compared to pre-pandemic levels, hospital admissions for spinal pathologies decreased significantly during all 5 waves of the pandemic and the proportion of spine patients with high HFRS increased from a range of 5.8-6.1% to 6.5-8.8% (p<0.01). Analogously, during all 5 waves, there was a significant increase in patient age (from 65.3-65.5 years to 65.8-66.5 years;p<0.01). The rate of comorbidities increased significantly, as well, with a rise in the Elixhauser Comorbidity Index from a range of 4.2-4.3 to 4.7- 5.9 (p<0.01). Throughout the pandemic, there was a significant increase in the rate of spinal fusion procedures among patients with low HFRS (from a range of 6.4-6.8% to 8.4-10.3%;p<0.01), as well as in the intermediate HFRS group (from 5.8-6.0% to 6.9- 7.8%;p<0.01). No changes in rates were observed for decompressive spine procedures, disc hernia resections, or kyphoplasty. Throughout all 5 pandemic waves, patients of the high HFRS group displayed significantly higher in-hospital mortality rates (8.6-13.6%) compared to patients in the low HFRS group (0.1-0.4%;p<0.01). Discussion(s): We present the largest study, to date, on frailty among patients with spinal pathologies in Germany. Our findings suggest that the COVID-19 pandemic has led to decreased numbers of hospital admissions for spinal pathologies but increased frailty among those hospitalized. This type of "negative selection" may be due to younger and healthier spine patients avoiding hospitalization out of fear of hospital-acquired COVID-19 infection. Among hospitalized spine patients with low or intermediate levels of frailty, the rate of spinal fusion procedures increased during the pandemic, while rates of non-fusion procedures were not impacted.
ABSTRACT
Introduction: To investigate the effects of the COVID-19 pandemic on epidural steroid injection treatment in elderly patients and to inform our colleagues to take possible precautions concerning treatment strategies. Materials and Methods: Retrospectively, patients who received lumbar epidural steroid injections between January 2019 and March 2021 were included in the study. The procedures performed between January 2019 and January 2020 before the pandemic were classified as Group A, and those performed during the pandemic period between March 2020 and March 2021 were classified as Group B. Demographic data, baseline pain scores, and waiting times for procedures and medical treatments in both groups were compared. Results: There were 186 and 81 patients in groups A and B, respectively. The mean age was 74 in Group B and 73 in Group A. Lumbar spinal stenosis and disc herniation were the most common diagnoses in both groups. The waiting time for epidural steroid injection was 39.4 days (0–160) in group B and 23.4 days (0–149) in group A. There was no significant difference between the two groups in terms of medical treatment for neuropathic pain. Conclusions: COVID-19 has caused a significant decrease and delay in the number of epidural procedures related to lower back pain in elderly patients. In the future, this decrease may create a burden on the health system. However, more observational and prospective studies are needed to inform our colleagues about the possible effects of COVID-19 on the elderly.