The Limitation of Endoscopic Surgery Using the Full Endoscopic Discectomy System for the Treatment of Destructive Stage Pyogenic Spondylodiscitis: A Case Series.

INTRODUCTION: Conservative therapy, including appropriate antibiotics and bracing, is usually adequate for most patients with pyogenic spondylodiscitis. If conservative treatment fails, surgical intervention is needed. However, major spinal surgery comprising anterior debridement and accompanying bone grafting with or without additional instrumentation is often related to undesired postoperative complications. In recent years, with minimally invasive surgery, the diagnostic and therapeutic value of endoscopic lavage and drainage has been proven. This study reports a case series of patients who required open revision surgery after treatment with endoscopic surgery using the full endoscopic discectomy system (FED), indicating the surgical limitations of endoscopic surgery for pyogenic spondylodiscitis. METHODS: We retrospectively investigated the medical records of 4 patients who underwent open debridement and anterior reconstruction with posterior instrumentation following endoscopic surgery for their advanced lumbar infectious spondylitis. They had been receiving conservative treatment with antibiotics for 12-15 days. They also had various comorbidities, including kidney disease, heart failure, and diabetes. Numerical rating scale pain response, perioperative imaging studies, and C-reactive protein (CRP) levels were determined, and causative bacteria were identified. Primarily, the bone destruction stage was classified using computed tomography with reference to Griffiths' scheme. RESULTS: All patients had severe back pain before surgery with no relief of the pain after FED. Increased pain, including radicular pain after FED, was noted in one case. Causative pathogens from biopsy specimens were identified in 3 (75%) of the 4 cases. In preoperative radiological evaluation, all cases were classified as destructive stage in Griffiths' scheme. The CRP levels of all the patients decreased slightly after endoscopic surgery. Relapse of spinal infection after revision surgery was not noted in any patient during the follow-up period. CONCLUSION: The surgical treatment of destructive-stage spondylitis with FED alone can increase low back pain due to aggressive debridement.

A Rare Case of Thoracic Pyogenic Facet Joint Infection.

Pyogenic facet joint infection is a rare but severe infection. The most common complaint on presentation is pain 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 thoracic spine. The patient was a 48-year-old immune-competent female who presented with left back pain. Magnetic resonance imaging (MRI) indicated a facet effusion, paraspinal abscess, and epidural abscess in the level of 9th-11th thoracic vertebra. On the 6th day of treatment, she presented a neurological disorder and underwent decompressive laminectomy and surgical debridement. We observed immediate improvement as a result of the surgery.

Initial Clinical Outcomes of Percutaneous Full-Endoscopic Lumbar Discectomy Using an Interlaminar Approach at the L4-L5.

BACKGROUND: Percutaneous full-endoscopic discectomy (PED) is being increasingly used because of its potential to minimalize soft-tissue damage and decrease hospital stay. PED using the interlaminar approach (PED-IL) at L4-L5 is performed by only a few surgeons. To the best of our knowledge, the safety and efficacy of PED-IL at L4-L5, without experience in PED via a transforaminal approach (PED-TF) has not been previously reported. OBJECTIVE: This study aimed to evaluate initial clinical outcomes and complications of PED-IL at L4-L5 without experience in PED-TF. STUDY DESIGN: Retrospective evaluation. SETTING: An urban minimally invasive spine hospital. METHODS: Of a total of 50 patients (36 men and 14 women, ages ranging from 21-59 years, with the average age being 40.3 years old), 16 cases were performed at L4-L5 and 34 cases were performed at L5-S1. PED-IL was successfully completed in all cases, and no case required conversion to open surgery. The operative time, hospital stay, modified MacNab criteria, and visual analog scale (VAS) scores were examined at L5-S1 (range: 41-112). There was no significant difference in operative time between the L4-L5 and L5-S1 groups; the operative time was gradually decreased. The mean hospital stay was 2.9 days (range: 2-8 days). According to modified MacNab criteria, 20 cases (6 at L4-L5 and 14 at L5-S1) were excellent, 27 (10 at L4-L5 and 17 at L5-S1) were good, one at L5-S1 was fair, and 2 at L5-S1 were poor. Two perineurium tears occurred at L5-S1. There was no infection or recurrence of herniated nucleus pulposus (HNP). The clinical outcomes of PED-IL at L4-L5 were equal to those at L5- S1. RESULTS: The mean operative time was 71.3 ± 19.3 minutes for all cases (range: 41-112 mins.),76.1 ± 16.8 minutes at L4-L5 (range: 52-102 mins.), and 70.5 ± 20.1 minutes at L5-S1 (range: 41-112 mins.). LIMITATIONS: A small sample size and a short follow-up period. CONCLUSIONS: The clinical outcomes of PED-IL at L4-L5 were equal to those at L5-S1. Therefore, PED-IL is suitable to be a standard method for any type of intracanalicular disc herniation.

A case of SAPHO syndrome with destructive spondylodiscitis suspicious of tuberculous spondylitis.

We report a rare case of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome in which the differential diagnosis included tuberculous spondylitis and the patient ultimately required reconstructive spinal surgery. The patient was a 60-year-old woman who presented with severe low-back and leg pain after treatment for tuberculosis. Roentgenography and magnetic resonance imaging of the lumbar spine revealed destructive changes suggestive of tuberculous spondylitis. [(18)F]-fluoro-2-deoxyglucose positron emission tomography/computed tomography showed uptake in the cervical spines, lumbar spines, and sacroiliac joints from which she was suspected of having SAPHO syndrome without skin manifestations. However, as her symptoms did not respond to conservative treatment, we performed reconstructive surgery of the lumbar spine. Spinal specimens obtained surgically showed nonspecific inflammation and fibrous hypertrophy of the bone marrow, confirming a diagnosis of the SAPHO syndrome. Her symptoms improved markedly after surgery, although she required occasional prednisolone for moderate polyarthralgia and leg pain.

Relationship between structures and biological activities of mycoplasmal diacylated lipopeptides and their recognition by toll-like receptors 2 and 6.

The lipopeptide FSL-1 [S-(2,3-bispalmitoyloxypropyl)-Cys-Gly-Asp-Pro-Lys-His-Pro-Lys-Ser-Phe, Pam(2)CGDPKHPKSF] synthesized on the basis of the N-terminal structure of a Mycoplasma salivarium lipoprotein capable of activating normal human gingival fibroblasts to induce the cell surface expression of ICAM-1 revealed an activity to induce production of monocyte chemoattractant protein 1, interleukin-6 (IL-6), and IL-8. FSL-1 also activated macrophages to produce tumor necrosis factor alpha as the Mycoplasma fermentans-derived lipopeptide MALP-2 (Pam(2)CGNNDESNISFKEK), a potent macrophage-activating lipopeptide, did. The level of the activity of FSL-1 was higher than that of MALP-2. This result suggests that the difference in the amino acid sequence of the peptide portion affects the activity because the framework structure other than the amino acid sequence of the former is the same as that of the latter. To determine minimal structural requirements for the activity of FSL-1, the diacylglyceryl Cys and the peptide portions were examined for this activity. Both portions did not reveal the activity. A single amino acid substitution from Phe to Arg and a fatty acid substitution from palmitic acid to stearic acid drastically reduced the activity. Similar results were obtained in measuring the NF-kappaB reporter activity of FSL-1 to human embryonic kidney 293 cells transfected with Toll-like receptor 2 and 6, together with a NF-kappaB-dependent luciferase reporter plasmid. These results suggest that both the diacylglyceryl and the peptide portions of FSL-1 are indispensable for the expression of biological activities and for the recognition by Toll-like receptors 2 and 6 and that the recognition of FSL-1 by Toll-like receptors 2 and 6 appears to be hydrophobic.

Mycoplasmal lipoproteins induce toll-like receptor 2- and caspases-mediated cell death in lymphocytes and monocytes.

Lipoproteins of Mycoplasma salivarium and Mycoplasma fermentans preferentially induced necrotic cell death in lymphocytic cell lines, MOLT-4 and Raji, and in one monocytic cell line, THP-1, whereas they preferentially induced apoptotic cell death in another monocytic cell line, HL-60. These findings were also supported by ultrastructural observations by the use of scanning and transmission electron microscopes and by agarose gel electrophoresis of the genomic DNA. The lipoproteins activated caspase-3 in both MOLT-4 and HL-60 cells, which was assessed by the cleavage of the synthetic substrate DEVD-pNA and the endogenous substrate poly(ADP-ribose) polymerase. The cytotoxicity to MOLT-4 and HL-60 cells was inhibited by various caspase inhibitors, Ac-DMQD-CHO, Ac-IETD-CHO, and Z-VAD-FMK. The cytotoxicity was also partially suppressed by the monoclonal antibody to Toll-like receptor 2. Thus this study demonstrated that mycoplasmal lipoproteins induce caspases-dependent necrotic and apoptotic cell death in lymphocytes and monocytes/macrophages, which is partially induced by TLR2-mediated signaling.

Signaling pathways induced by lipoproteins derived from Mycoplasma salivarium and a synthetic lipopeptide (FSL-1) in normal human gingival fibroblasts.

Lipoproteins derived from Mycoplasma salivarium and a synthetic lipopeptide (FSL-1) activate human gingival fibroblasts to induce IL-6 production and ICAM-1 expression. Human gingival fibroblasts were treated with lipoproteins or FSL-1 and then examined for the activation of mitogen-activated protein kinases (MAPKs), ERK1/2, p38, and SAPK/JNK, and transcription factors, AP-1 and NF-kappaB. Western blotting indicated that p38 and SAPK/JNK were activated in response to the stimulators, but the activation of ERK1/2 could not be discriminated because ERK1/2 was activated in the absence of stimulators. The p38 inhibitor SB 203580 also suppressed their IL-6 production-inducing activities, whereas the ERK1/2-activating MAPK kinase (MEK1) inhibitor PD 98059 did not suppress their activities. Moreover, they were capable of inducing the activation of AP-1 and NF-KB. NF-kappaB activation was also confirmed by the phosphorylation of IkappaB-alpha. On the basis of these results, it was concluded that lipoproteins of M. salivarium and FSL-1 are capable of activating the MAPKs p38 and SAPK/JNK and the transcriptional factors AP-1 and NF-kappaB in human gingival fibroblasts.