Mathew V. Smith

BACKGROUND AND PURPOSE: Studies show a modest yield for image-guided biopsy of suspected vertebral osteomyelitis-discitis. Many studies evaluate factors to improve diagnostic yield, and few studies assess how biopsy results impact clinical management. We aim to evaluate the impact of biopsy results on clinical management in suspected vertebral osteomyelitis-discitis. MATERIALS AND METHODS: We performed a retrospective study of patients who underwent image-guided biopsy for suspected vertebral osteomyelitis-discitis. Data collected included risk factors, imaging findings, laboratory values, antibiotics, biopsy procedure details, microbiology and pathology results and clinical course. Factors assessed for management change included whether biopsy results affected antibiotic type or course, decision to start or stop antibiotics, surgical decisions or if an alternate diagnosis was determined. RESULTS: 310 biopsies were included. Biopsy yield with true positive culture results was 34% (104/310) and similar for patients on antibiotics (36%, 34/94) and off antibiotics (32%, 66/204). Yield was greater when disc was sampled (36%, 82/228) versus bone only (8%, 2/24) and with aspiration of disc and/or bone (42%, 39/92) versus core only (29%, 56/193). With positive blood cultures prior to biopsy, biopsy yield was 50% (22/44) with concordance and discordance rates of 75% (18/24) and 17% (4/24) respectively, and 8% (2/24) of positive biopsy results deemed contaminants. Management was affected in 36% (113/310) of all biopsies and in 78% (81/104) of biopsies with a positive culture result. No management change occurred in 57% (177/310) of biopsies. Management change was unclear in 6% (20/310). Biopsy results changed antibiotics in 27% (85/310). Management change occurred in 23% (10/44) of cases with prior positive blood culture compared to 41% (93/233) without a prior culture source (P = 0.024). Negative culture results influenced management in 16% (32/194). CONCLUSIONS: Image-guided biopsy for vertebral osteomyelitis-discitis has a meaningful impact on management despite modest yield. Greatest management impact is seen with positive culture results, no prior culture source and patients not on antibiotics at the time of biopsy. Biopsy culture yield is not affected by preceding antibiotics, and yield is greater with disc sampling and aspiration. ABBREVIATIONS: VO = vertebral osteomyelitis-discitis; WBC = white blood cell count; ESR = erythrocyte sedimentation rate; CRP = C-reactive protein; MC = management change; NMC = no management change; UC = unclear management change; Abx = antibiotics

Bronchial-subarachnoid fistulas are rare occurrences, which are not well defined in the literature. This uncommon clinical phenomenon may result in symptomatic pneumorrhachis and presents unique clinical challenges. This report details a case of a 53-year-old female whose treatment for recurrent chondrosarcoma of the thoracic spine included multiple surgeries and radiotherapy. Two weeks after her most recent debulking surgery, she experienced a rapid onset of unusual symptoms, including headache, back and neck spasms, bladder incontinence, and confusion. The source of her symptoms was found to be secondary to pneumorrhachis from a pre-existing bronchial-pleural fistula that had fistulized to the subarachnoid space discovered on computed tomography (CT) and confirmed intraoperatively. The patient was treated successfully with high-flow oxygen therapy and bed rest, followed by surgical correction of both a pleural air leak and a dural defect with muscular flaps. The patient was discharged home in stable condition and remained clinically free of recurrent bronchial-subarachnoid fistula six months after surgical repair. This case contributes to the existing literature by providing detailed clinical insights into the diagnosis and successful management of a bronchial-subarachnoid fistula leading to pneumorrhachis, thereby highlighting the importance of early recognition and intervention and underscoring the need for further research in this area.

The use of percutaneous transsplenic access has increased for treatment of a large range of portal system abnormalities and interventions, with current evidence demonstrating high technical success... Multiple diseases of the portal system require effective portal vein access for endovascular management. While percutaneous transhepatic and transjugular approaches remain the standard methods of p...