Leadership and teamwork in nursing

Leadership and teamwork in nursing crimpIntroduction The interposition of vertebral osteomyelitis includes antibiotics with or without functional intervention. Debridement is warranted for the preaching of idiopathic spondylo-discitis in case of neurologic shortages, de diversenessity, instability, abscess inventation, intractable pain or ill fortune of medical examination man growment. The use of instrumentality is still controversial.Objective Is to evaluate the working(a) outcome of idiopathic lumbar spondylodiscitis treated with tail debridement combined with single-stage bum instrumentality and autologus bone embeding.Methods This backward canvas was conducted to evaluate the outcome of 15 cases of idiopathic lumbar spondylo-discitis treated with posterior debridement combined with single-stage posterior orchestration and grafting. All patients were followed up for up to 1 year post-operative. We evaluated operative quantify, argumentation passing, and complic ations. Visual analogue scale (VAS), activities of daily living (ADL) (Barthel index), C unstable proteins (CRP), and Erythrocyte sedimentation mark (ESR) in the preoperative, postoperative and final run through arrests were used to evaluate the surgical outcome.Results All 15 cases of lumbar infections intractable without recurrence. Bony union was obtained in solely cases. Twelve out of 15 patients (80%) were completely relieved of pain and fully active with improvement neurologic deficits, while the other 3 patients (20%) obtained a good result. no(prenominal)post-operative major complications were reported among the studied group. There were two superficial infections, which healed with debridement and antibiotics. oddment According to the results reported in this short study, the proposed technique is an effective and right intervention for idiopathic lumbar spondylo-discitis, if surgery is mandatory.Keywords spondylo-discitis, debridement, posterior statistical regr ession.INTRODUCTIONThe increase number of spinal infections has become a global health concern. It is shortly due to reactivation of latent infections, more drug resistant agents and more immuno-compromised patients. It has been shown that custody in diagnosing kitty lead to increased morbidity and mortality, archeozoic diagnosis and sermon are in that locationfore of paramount importance.(1)Spinal infections track a spectrum of conditions comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, epidural infection, meningitis, polyradiculopathy and myelitis. All of these have a specific presentation and clinical course.(2)Osteomyelitis of the book binding accounts for approximately 1 to 7% of all osseous infections. In recent years, there have been an change magnitude incidence of spinal infections, which is now estimated to occur in approximately 1/100,000 individuals annually. This rise may be attributed to the increasing prevalence of elderly and i mmuno-compromised individuals in the population.(3)The predominant organism in almost all studies is staphylococcus aureus, accounting system for approximately 40 to 80% of all spinal infections. about other confirming organisms such as S. epidermidis and Streptococcus species are also normal.(4)Establishing the diagnosis of vertebral osteomyelitis in a punctual fashion is critical to maintaining catastrophic neurological injury. In the modern imaging era, magnetic resonance imaging, in particular, has facilitated the diagnosis of osteomyelitis even before the onset of neurological signs or symptoms. Nevertheless, despite advancements in diagnosis, there roosts disagreement regarding appropriate preaching. Antibiotics are the main- occlusive of therapy.(5)The treatment of pyogenic spondylodiscitis with intravenous antibiotics is universally agreed upon. More than 75% of patients can be treated with intravenous antibiotics and immobilization.(6)Although no difference in cl inical outcomes has been observed when comparing antibiotics wholly with antibiotics plus surgical debridement, debridement of infect and out of work tissue removes the source of continuing sepsis, may allow shorter courses of antibiotic treatment and may also allow early mobilization of the patient.(7)Surgery is slackly reserved for patients with neurological involvement, spinal instability, severe deformity, and/or those in whom antibiotics alone have non been effective. Current surgical treatment options include introductory or posterior decompression with or without fusion, and with or without orchestration. The fact that there exist several alternative surgical approaches heightslights the lack of a consensus on the optimal operative treatment for vertebral osteomyelitis. The decision to shoes instrumentation into an infected spinal tugboat remains controversial. Numerous authors have shown that instrumentation in patients with osteomyelitis can be performed safely.(8 )There is still controversy just about the best surgical treatment. Many spine surgeons are unwilling to place an implant in an infected area. Some authors go one quality further and advocate debridement-only surgery, followed by antibiotic treatment and second- stage instrumentation. Other authors propose single-stage anterior decompression, bone grafting and instrumentation.(9)Aim of the workThe force back of this retrospective study was to evaluate the surgical outcome of idiopathic lumbar spondylodiscitis treated with posterior debridement combined with single-stage posterior instrumentation and autologus bone grafting.METHODSThis retrospective study included 15 patients (9 males, 6 females) with a rigorous age of 66 years (range 43-80) who were admitted to El-Menoufia University Hospitals Neurosurgical Department, in the period from Aug 2007 to Nov 2008.The inclusion criteria weremagnetic resonance imaging of lumbo-sacral spine showing evidence of spondylodiscitis.Plain rad iographs revealed disc space narrowing with corrosion and sclerosis of the adjacent end-plates.Persistent high levels of research lab tests white broth cell count (WBC count/mm3), C-reactive protein (CRP mg/dl) and erythrocyte sedimentation rate (ESR mm/h).Failure of conservative treatment for about 3 months. reading of neurological deficit.The exclusion criteria were Postoperative spondylodiscitis. Decreasing ESR and CRP levels with conservative treatment. medically unfit patients.The mean succession of symptoms before admission was 3.7 months (range 0.5 to 12 months) and the mean duration of conservative treatment before surgery was 2.2 months (range 1 to 3 months). The average follow-up period was 12 months.Six out of 15 patients (40 %) had an elevated white declivity cell count, while all 15 had an elevated ESR and CRP level .Plain radiographs, magnetic resonance imaging (MRI) with and without argument were performed in all patients. Conservative treatment was given to all cases preoperatively in the form of two bactericidal and synergistic antibiotics were administered intravenously in high doses mostly a outset-generation cephalosporin and an aminoglycoside. Postoperatively, the antibiotics were adapted to the antibiogram performed on the specimens obtained. The duration of treatment was determined by the clinical evolution, the ESR and the C-reactive protein. Generally speaking, the antibiotics were administered intravenously for 6 weeks, and orally for 6 weeks.Patients were operated in the prone position for the posterior instrumentation and grafting. A meticulous debridement of all granulation tissue, devitalized disc and sequestra was carried out to the rank where healthy cancellous bone is exposed. Wide decompression of the thecal sac was done, with drainpipe of any epidural abscess and depridment of any necrotic tissue, which were submitted for bacteriological tillage and sensitivity, and histologic examination. Finally, trans-pedicular s crew fixation was done combined with autologus done chips graft. Postoperatively all patients were immediately mobilized with an external lumbo-sacral orthosis. Duration of surgery and operative blood loss were recorded.The clinical outcome was assessed according to Barthel Index,(10) which has been used since the 1960s because of its high reliability and validity, as regards the activities of daily living (ADL), and the VPAS as regards the severity of back pain. flesh 1 Preoperative sagittal MRI-scan of the lumbar spine. T2-weighted images showing L3-L4 spondylodiscitis.Fig 2 A, B. Postoperative antero-posterior and lateral radiographs showing L3-L4 posterior trans-pedicular screw fixationRESULTS afterward surgery, infection was successfully controlled in all patients, with return of the white blood cell count, ESR and CRP to normal within a mean period of 4 months (range, 2 to 6 months). Two patients (13% of cases) had a superficial scandalize infection which healed with debride ment and antibiotics. The estimated blood loss was 650 ml (range 450-1000 ml). The mean duration of surgery was 3 hours (range 2 hours to 4 hours). Bony fusion with internalization of the graft was achieved in all patients..Table I Pre-operative clinical presentationsNo.%Persistent low back pain15100 %Radiculopathy1280 %Constitutional symptoms640 %Table II Pre-operative laboratory findingsNo.%Elevated ESR15100 %Elevated CRP1066 %Leukocytosis640 %Table III Pre-operative radiological take aimNo.%L 3/4 spondylodiscitis853 %L4/5 Spondylodiscitis533 %L5/S1 Spondylodiscitis214 %Table IV Associated jeopardy factorsNo.%DM533 %Chronic Liver complaint214 %Urinary tract infection428 %Table V Post-operative outcome accordingto Barthel IndexNo.% nice1280 %Good320 %Total15100 %DISCUSSIONAlthough there have been advances in diagnosis and treatment of spinal infections with further refinement of microbiological and histopathological techniques, early detection and management remain a matter of considerable difficulty.(11)A correct diagnosis may be delayed by more than a month in over two thirds of the patients. A rise in the worlds elderly and immuno-compromised populations is bringing an increased incidence of pyogenic and granulomatous infections of the spine, hence, timely diagnosis of pyogenic spondylodiscitis with back pain and fever may prevent greater tissue destruction, spinal instability and progressive neurological deficit. Advances in therapy have reduced mortality rates, but early diagnosis is intrinsic for a satisfactory outcome.(12)The exact cause of lumbar spondylodiscitis is controversial some authors opine that there are two types of spondylodiscitis, a septic form caused by an infectious agent and an aseptic form resulting from an inflammatory reaction. (13) Others call back that there is no such thing as an aseptic spondylodiscitis and that this form is actually the result of a less virulent, low grade infection.(14) erst inoculated, the process of infection and discitis begins. More than often, the main causative organism is not identified. When an organism is identified, the most common infectious etiologic agent is Staphylococcus aureus followed by other Staphylococcus species and anaerobic organisms. Other less common organisms include Streptococcus viridans and other Streptococcus species, Escherichia coli, Pseudomonas aeruginosa.(15)Traditionally, the mainstay treatment of pyogenic infections of the spine remains medical management, with external immobilization and culture specific antibiotics for a minimum of 4 to 6 weeks. However, large clinical serial publication have demonstrated the need for surgical intervention in up to 43% to 57% of the patients, in case of neurological compromise, deformity, instability, abscess formation, prolonged destruction, intractable pain or failure of medical management.(16)Because all the patients in our study were from the low socio-economic class and because of the difficulty to iden tify the causative organism, we elect not to perform CT guided biopsy and give the patients empirical capacious spectrum antibiotics covering both aerobic and anerobic pathogens.It has been reported that the most sensitive laboratory studies indicative of the presence of an inflammatory process are the ESR and the CRP.However, it should be noted that in fully growns, ESR trends are confused by associated medical conditions. Nevertheless, the ESR was a useful tool in the management of adult pyogenic spondylodiscitis, and the authors of most studies on this matter, view a 60 to 85% reduction in the ESR as compatible with eradication of infection, and this correlates with the results in our study which reported reduction of ESR in 80% of case.(17)MRI is the radiographic imaging modality of choice in diagnosing lumbar spondylodiscitis with a reported sensitivity and specificity of 93% and 97%, respectively. It has been shown that MRI is prize in showing loss of disc space height. Th is can be accompanied with erosion of the vertebral end plates above and below the infected disc space, and these changes were reported in all cases included in our study.(18)In the surgical treatment of spondylodiscitis, numerous authors have advocated a staged functioning with a period of antibiotic therapy bridging the debridement and instrumentation procedures. Open surgical drain for spondylodiscitis was historically reserved for patients with an epidural abscess. The prognosis is stated to be cleanse when treatment is instituted early during the infection.(19)Posterior debridement combined with trans-pedicular screw fixation has been advocated by several authors. Dai et al(20) obtained 100% of good results with this technique in a series of 22 cases and we used the same technique in this short study.The first series describing the consistent placement of posterior instrumentation at the time of debridement was published in 1988 by Redfern et al(21) In 1996, Rath et al(22) r eported on a series of 43 patients with thoracic or lumbar spondylodiscitis who were treated all via a posterior approach. This approach is based on the principle that instrumentation placed posteriorly involves a second operating field that is not (at to the lowest degree directly) contaminated.Single-stage procedure surgery (autograft and posterior instrumentation) was used in this study and its results correlates with the Kuklo et al(23) study which included 21 patients with pyogenic vertebral osteomyelitis managed by a single-stage with neither recurrence of infection nor perioperative complications. A single-stage procedure has several advantages, such as avoidance of a second anesthesia, reduced blood loss, avoidance of graft displacement during transfers, earlier mobilization, less anxiety for the patient, shortened hospital stay and less expense. (23)According to Barthel Index,(10) 80 % of our patients had an excellent result, without pain or childbed of activity. From a neurological viewpoint, ten patients (83%) of the 12 with a neurological deficit improved and these findings were consistent with Fayazi et al(24) who reported 85% improvement after posterior approach for lumbar spondylo-discitis.After posterior instrumentation, fusion rates up to 93% and 96% have been reported (25) the current study yielded a 100% fusion rate. As stated by Hadjipavlou et al(26) posterior stabilisation through instrumentation was the critical factor in these improved results. We believe that posterior instrumentation and grafting is the principal stabilizer of the vertebral column in order to achieve a successful fusion.ConclusionAlthough this is a limited series, we found that a posterior debridement combined with trans-pedicular screw fixation and autologus grafting may be a safe and effective surgical treatment for selected patients with lumbar spondylodiscitis and may not be associated with recurrent ironware infections and/or any major complications.