New classification for the treatment of pyogenic spondylodiscitis: validation study on a population of 250 patients with a follow-up of 2 years

Challenges and limitations of the existing scoring systems for postoperative outcomes in thoracolumbar pyogenic spondylitis: a multicenter retrospective cohort study

PURPOSE

This study aimed to evaluate the predictive ability of existing scoring systems for postoperative outcomes in patients with thoracolumbar pyogenic spondylitis treated with minimally invasive posterior fixation.

METHODS

We conducted a multicenter retrospective cohort study of 90 patients with thoracolumbar pyogenic spondylitis treated with minimally invasive posterior fixation between January 2014 and June 2024. We assessed the Brighton spondylodiscitis score (BSDS), spinal instability spondylodiscitis score (SISS), and spinal infection treatment evaluation (SITE) score. Patients were divided into success and failure groups based on infection control or implant failure. The predictive ability of each scoring system for treatment failure was evaluated using receiver operating characteristic (ROC) curves and area under the curve (AUC).

RESULTS

The success and failure groups consisted of 78 (87%) and 12 patients (13%), respectively, with the failure group including seven and five patients due to infection control or implant failure. The failure group had higher BSDS, SISS, and SITE scores, but the ROC analysis showed low predictive accuracy (AUC: BSDS = 0.65, SISS = 0.64, SITE score = 0.56). Grading the BSDS into three categories revealed no failure in the low-risk patients, whereas 22% of the high-risk patients required unplanned additional surgeries for infection control or implant failure.

CONCLUSIONS

Existing scoring systems showed limited ability to predict postoperative outcomes in patients with thoracolumbar pyogenic spondylitis treated with minimally invasive posterior fixation. BSDS grading demonstrated some utility, with 22% of high-risk patients experiencing postoperative infection control failure and implant failure, highlighting the need for careful treatment planning.

Local antibiotic carriers in the surgical management of pyogenic spondylodiscitis : First comparative evaluation of gentamicin-loaded versus vancomycin-loaded efficacy

OBJECTIVE

To evaluate the efficacy of intraoperative gentamicin versus vancomycin-loaded PerOssal (Osartis, Münster, Germany) carriers on interbody fusion rates and infection control in patients undergoing surgery for pyogenic spondylodiscitis.

METHODS

This retrospective study included 29 patients with pyogenic spondylodiscitis who underwent surgical debridement, interbody fusion, and pedicle screw fixation between February 2018 and March 2023. Patients received PerOssal carriers loaded with either gentamicin (Group A, n = 14) or vancomycin (Group B, n = 15). Clinical outcomes, including fusion rates, infection control, complications, and inflammatory markers, were analyzed.

RESULTS

Baseline characteristics between groups were comparable. Fusion rates at 3-6 months' follow-up were 92.8% (13/14) in Group A and 80.0% (12/15) in Group B, without significant differences (P > 0.05). Both groups showed significant reductions in white blood cell counts and C‑reactive protein levels postoperatively, without inter-group differences (P > 0.05). Complications included cerebrospinal fluid leakage, hematoma, pulmonary embolism, and wound infections, all managed successfully with no recurrent infections observed.

CONCLUSION

In the short term, PerOssal carriers loaded with either gentamicin or vancomycin demonstrated effective infection control for pyogenic spondylodiscitis and high interbody fusion rates. Moreover, no apparent adverse effects on bone healing were associated with the local administration of high-concentration antibiotics.

Early and late mortality in vertebral osteomyelitis: who dies within the first year after diagnosis

OBJECTIVE

Vertebral osteomyelitis (VO) is a severe clinical entity associated with high mortality rates, especially within the first year after diagnosis. The aim of this single-center prospective cohort study was to identify and compare predictive factors influencing early and late mortality in patients with conservatively and surgically treated VO.

METHODS

We conducted a single-center prospective cohort study including patients treated for VO between 2008 and 2020 in a tertiary center in Germany to determine early (death within 30 days after diagnosis) and late mortality (death between day 31 and 365 after diagnosis). Additionally, multivariable analyses were performed to analyze predictive risk factors for early and late mortality.

RESULTS

A total of 323 patients were included. 19% died within the first year after diagnosis. Early mortality occurred in 5% and late mortality in 14% of cases. Multivariable analysis revealed chronic kidney disease (CKD) (OR: 13.2, 95% CI 5.7-30.3; p < 0.001) and MSSA (OR: 4.0, 95% CI 1.4-11.1; p = 0.008) as independent risk factors for early mortality, whereas ASA score > 2 (HR: 5.2, 95% CI 2.6-10.6; p < 0.001), age > 70 years (HR: 2.4, 95% CI 1.6-3.7; p < 0.001), CKD (HR: 1.9, 95% CI 1.3-3.0; p = 0.003) and bacteremia (HR: 1.8, 95% CI 1.2-2.7; p = 0.002) were identified as independent risk factors for late mortality.

CONCLUSION

One out of five VO patients dies within the first year after diagnosis. Risk factors for mortality within the first year include CKD and bacteremia. As a consequence in particular those patients should be closely monitored within the first year after.

Uniportal endoscopic decompression and debridement for infectious diseases of spine with neurological deficits: a retrospective study in China

STUDY DESIGN

A retrospective study.

PURPOSE

To evaluate the clinical efficacy of uniportal endoscopic decompression and debridement (UEDD) in treating infectious diseases of the spine (IDS) with neurological deficits.

OVERVIEW OF LITERATURE

IDS patients with neurological deficits often require urgent surgical decompression. However, the efficacy of UEDD in this complex patient population is not well-characterized.

METHODS

This retrospective study analyzed 32 consecutive IDS patients who underwent UEDD surgery. Clinical features, laboratory data (erythrocyte sedimentation rate and C-reactive protein), and treatment outcomes were analyzed.

RESULTS

Definite microorganisms were identified in 27 patients (84.3%), with 24 (88.9%) meeting cure criteria. The cure rate was significantly higher in the detected pathogen group compared to the undetected pathogen group (88.9% vs. 80%; χ²=19.36, p<0.0001). Metagenomic next generation sequencing (mNGS) provided faster diagnosis (41.72±6.81 hours) compared to tissue culture (95.74±35.47 hours, p<0.05). The predominant causative pathogen was Mycobacterium tuberculosis, followed by Staphylococcus aureus. Significant improvements were observed in Visual Analog Scale pain scores, from a mean of 7.9 preoperatively to 1.06 at 1 year postoperatively. The Oswestry Disability Index revealed a similar trend, showing significant improvement (p<0.05).

CONCLUSIONS

UEDD is a viable alternative to traditional open surgery for managing IDS in high-risk patients. UEDD offers a dual therapeutic-diagnostic advantage during the initial admission phase, enabling simultaneous debridement, neurological decompression, and targeted biopsy in a single intervention. Compared with traditional tissue culture, mNGS enables rapid microbiological diagnosis and extensive pathogen coverage.

[Brucella spondylodiscitis and factors associated with prognosis: a case series from Sétif, Algeria]

Introduction and objectives

Spondylodiscitis is a serious and suggestive complication of brucellosis. Few studies have been devoted to it in Algeria, although the infection remains a public health problem. The aim of this study was to report the epidemiological and clinical aspects of brucellosis spondylodiscitis and to identify the neurological complications.

Material and methods

This is a descriptive analysis of a cohort of adult patients with Brucella spondylodiscitis, based on data collected from patient records recruited between January 2016 and December 2022.

Results

Thirteen females and 24 males with a mean age of 48 ± 15 years [21 to 71 years] were included in the study. Diagnosis was made on average 120 days ± 100 [30-360] after the onset of clinical symptoms. Commonly reported symptoms were: back pain (100%), fever (46%), sweating (70%), asthenia (84%), chills (22%), and weight loss (27%). Neurological complications were numerous and sometimes varied in the same patient: one case of paraplegia, three cases of paraparesis, six cases of sensory disturbances, and one case of sphincter disorders. Involvement of the lumbar spine was predominant, observed in 22 patients, including 15 at the L4-L5 level.In addition to discovertebral lesions, imaging revealed 27 cases of epiduritis, 13 cases of spinal cord compression, 25 cases of radicular compression, and pre- or para-vertebral and psoas abscesses.Two treatment regimens were used: doxycycline-cotrimoxazole-gentamycin (22 cases) and doxycycline-rifampicin-gentamycin (15 cases). At the end of the one-year post-therapeutic follow-up, we observed one relapse, sequelae of paraparesis, and sequelae of spinal pain in 12 patients.

Discussion and conclusion

This study has allowed us to observe prognostic elements. Early spinal imaging is essential to combat the excessive delay in diagnosis in our patients. There is no clear consensus in the scientific literature regarding neurological complications, such as epiduritis, and optimal treatment. The results of our study may contribute to the development of more personalized management algorithms.

Clinical and demographic characteristics of spondylodiscitis in a Mexican population: A retrospective study

The aim of this study was to identify the clinical and demographic characteristics of patients with a confirmed diagnosis of spondylodiscitis through microbiological cultures. A descriptive, observational, and retrospective study was conducted. Patients were included based on clinical and radiological evidence of vertebral infection, unspecified discitis, and/or positive microbiological cultures consistent with spondylodiscitis. For the comparison between men and women, the Student's t-test and odds ratio were employed. The Chi-square test was used to examine correlations between affected spinal levels, isolated microorganisms, and associated comorbidities. A total of 86 cases of discitis were identified, 65% of which involved male patients. The mean age was 59.0±11.5 years (range: 38-83), and the average body mass index (BMI) was 28±4.05kg/m2. Primary discitis predominated in 68% of cases, mainly at the thoracic level. Seventeen patients presented with spondylodiscitis not associated with chronic degenerative diseases. The most frequently isolated microorganisms were Staphylococcus aureus (28 cases) and Escherichia coli (21 cases). In 16 cases, intracellular pathogens such as Mycobacterium tuberculosis and Brucella spp. were identified, leading to an average hospital stay of 30 days. Spondylodiscitis is a serious complication, and this study highlights differences from previously published data, particularly in terms of the microorganisms involved and the demographic profile of the population.

Sagittal Parameters and Clinical Outcomes in Cervical Spondylitis: The Cohort Analysis

BACKGROUND

Cervical spondylitis is accompanied by segmental instability and sagittal imbalance. The purpose of this work is to conduct a search of correlation between sagittal parameters and clinical outcomes in cervical spondylitis.

MATERIALS AND METHODS

The monocentric cohort study encompassed the clinical and radiological data of 59 patients who underwent reconstructive surgeries on the suboccipital, subaxial, and cervicothoracic spine. We evaluated local cervical sagittal parameters: cervical sagittal vertical axis (CSVA), T1 slope (T1S), Health-Related Quality of Life-HRQOL (Oswestry Disability Index-ODI)-and others pre- and postoperatively.

RESULTS

The duration of the therapeutic pause and T1S correlated with HRQOL. It revealed the direct relationship between the age of the patient and the value of CSVA. A significant predictor of postoperative complications is the level of comorbidity with an index of 7 or more on the Charlson scale.

CONCLUSIONS

The factors influencing HRQOL in this pathology are the duration of the therapeutic pause and the magnitude of T1S compensation. Anterior reconstruction of the cervical spine in the presence of spondylitis yields a correction of the sagittal balance parameters. The leading predictors of complications from the surgical treatment of cervical spondylitis are the Charlson comorbidity index and the variant of anterior reconstruction.

Wide variability of the definitions used for native vertebral osteomyelitis: walking the path for a unified diagnostic framework with a meta-epidemiological approach

BACKGROUND CONTEXT

Native Vertebral Osteomyelitis (NVO) has seen a rise in incidence, yet clinical outcomes remain poor with high relapse rates and significant long-term sequelae. The 2015 IDSA Clinical Practice Guidelines initiated a surge in scholarly activity on NVO, revealing a patchwork of definitions and numerous synonyms used interchangeably for this syndrome.

PURPOSE

To systematically summarize these definitions, evaluate their content, distribution over time, and thematic clustering.

STUDY DESIGN/SETTING

Meta-epidemiological study with a systematic review of definitions.

PATIENTS SAMPLE

An extensive search of multiple databases was conducted, targeting trials and cohort studies dating from 2005 to present, providing a definition for NVO and its synonyms.

OUTCOME MEASURES

Analysis of the diagnostic criteria that composed the definitions and the breaking up of the definitions in the possible combinations of diagnostic criteria.

METHODS

We pursued a thematic synthesis of the published definitions with Boolean logic, yielding single or multiple definitions per included study. Using 8 predefined diagnostic criteria, we standardized definitions, focusing on the minimum necessary combinations used. Definition components were visualized using Sankey diagrams.

RESULTS

The literature search identified 8,460 references, leading to 171 studies reporting on 21,963 patients. Of these, 91.2% were retrospective, 7.6% prospective, and 1.2% RCTs. Most definitions originated from authors, with 29.2% referencing sources. We identified 92 unique combinations of diagnostic criteria across the literature. Thirteen main patterns emerged, with the most common being clinical features with imaging, followed by clinical features combined with imaging and microbiology, and lastly, imaging paired with microbiology.

CONCLUSIONS

Our findings underscore the need for a collaborative effort to develop standardized diagnostic criteria. We advocate for a future Delphi consensus among experts to establish a unified diagnostic framework for NVO, emphasizing the core components of clinical features and MRI while incorporating microbiological and histopathological insights to improve both patient outcomes and research advancements.

The Never Ending Story-What Are the Differentiable Magnetic Resonance Imaging Characteristics Between Pyogenic and Mycobacterial Thoracolumbar Infections?

Background/Objectives: This study aimed to determine if MRI features can distinguish between spinal infections caused by pyogenic bacteria and Mycobacterium tuberculosis. Methods: Patients underwent an MRI of the thoracolumbar spine with and without contrast. Three blinded observers assessed the images, using statistical tests for analysis. Results: Demographic characteristics and symptom duration were similar between patients with tuberculous and pyogenic spinal infections. In 36 cases of pyogenic infections, the MRI showed weakly delineated paravertebral tissue enhancement (76%), a hyperintense signal in the T2 TIRM sequences (89%), and homogeneous vertebral body enhancement (89%). In 32 cases of Mycobacterium infections, the MRI revealed well-delineated paravertebral changes, mixed vertebral body signals, and variable enhancement. Pyogenic infections were more often found in the lumbar spine (67%) and typically involved two vertebrae, while tuberculous infections preferred the thoracic spine (75%) and often involved two vertebrae, with 25% affecting three or more vertebrae. Conclusions: The MRI features can help differentiate between pyogenic and tuberculous spine infections, though none are definitive. The study suggests that MRI can be used for initial differentiation or as a diagnostic tool when biopsy or surgical exploration is not possible.

Unique characteristics of bone union at the infected vertebrae after minimally invasive posterior fixation without bone grafting in thoracolumbar pyogenic spondylitis: a retrospective multicenter cohort study

BACKGROUND

The current study aimed to evaluate the bone union rate between infected vertebrae after minimally invasive posterior fixation without bone grafting in thoracolumbar pyogenic spondylitis.

METHODS

This retrospective multicenter cohort study evaluated 75 patients of posterior fixation for thoracolumbar pyogenic spondylitis that have been recorded at six relevant institutions from January 2016 to December 2022. Data on age, sex, location of infected vertebrae, number of infected disks, comorbidity, Pola classification, number of vertebrae fixed according to surgery, implant failure requiring revision surgery, and distance according to the type of infected vertebrae after surgery were evaluated. Further, their association with postoperative bone union was investigated > 12 months postoperatively.

RESULTS

Finally, 40 patients were included in the study. In total, 32 (80%) patients achieved bone union at the infected vertebrae after minimally invasive posterior fixation without bone grafting. The mean duration from surgery to union was 10.7 months. Twenty-six (65%) patients initially achieved bone union at the lateral and/or anterior bridging callus. Patients with multiple-level infected disks (33%, 2/6 patients) had a lower bone union rate than those with a single-level infected disk (88%, 30/34 patients) (p = 0.0095).

CONCLUSIONS

In 80% of patients, bone union at the infected vertebrae was achieved after minimally invasive posterior fixation without bone grafting in thoracolumbar pyogenic spondylitis. A total of 65% of the patients achieved initial bone union at the lateral and/or anterior bridging callus. Moreover, patients with multiple-level infected disks had a low bone union rate. Hence, the treatment strategy should be cautiously considered.

TRIAL REGISTRATION

This study was registered retrospectively and all procedures used in this study including the review of patient records were approved by the institutional review board.

Comparing Conservative and Early Surgical Treatments for Pyogenic Spondylodiskitis: An International Propensity Score-Matched Retrospective Outcome Analysis

BACKGROUND AND OBJECTIVES

Pyogenic spinal infections pose therapeutic challenges, with the optimal treatment approach remaining contentious. This study aimed to compare outcomes of conservative vs early surgical treatment (SuT) modalities in primary pyogenic spondylodiskitis through an international cohort analysis.

METHODS

A retrospective outcome analysis was conducted of 392 patients from the United Kingdom and Germany, treated between 2017 and 2022 with primary pyogenic spondylodiskitis. Patients were stratified by treatment modality. Propensity score matching, facilitated by a directed acyclic graph and principal component analysis, was used to balance risk factors between the compared patient cohorts. Primary outcome was mortality rate, while secondary outcomes included hospitalization duration, infection relapse, and neurological status at discharge.

RESULTS

The study included 95 patients undergoing conservative treatment, primarily treated in the United Kingdom, and 297 receiving SuT, predominantly in Germany. The mortality rate was notably higher in the conservative group ( P < .001), while the surgical cohort experienced a shorter hospitalization duration ( P < .01). After propensity score matching, 2 comparable cohorts of 95 patients each emerged. Subsequent analysis revealed a markedly increased mortality in the conservative group (24.2% for conservative treatment vs 4.2% for SuT, P < .001). Neither relapse nor neurological status at discharge showed significant differences between the groups.

CONCLUSION

The study indicates that early surgical intervention may be more effective than conservative management in reducing mortality and hospital stay for patients with primary pyogenic spondylodiskitis. These findings highlight the need for prospective trials and more definitive treatment guidelines.

MRI findings and classification of brucella spondylitis: a China multicenter study

OBJECTIVES

To propose a magnetic resonance imaging (MRI) classification of brucellosis spondylitis (BS) to determine a standard treatment method and a standard of post-treatment MRI follow-up.

METHODS

This is a multicenter retrospective cohort study. All patients diagnosed with BS at six hospitals for 12 years, were included in the study. Data were collected retrospectively from the medical records of the patients. The classification of the cases was based on MRI. We analyzed MRI features of BS was categorized them into three types.

RESULTS

Six hundred fifteen patients were included in the study, 78.9% of whom were males. The mean age was 53.05 ± 11.06 years. Involvement of single vertebrae occurred in 6.2% of patients, while 72.7% involved two vertebrae and 21.1% involvement of more than two vertebrae. The most common of the lumbar spine was 64.6%. The main findings of MRI were affected vertebral endplate 2/3 above (60.7%), intervertebral space narrow (77.9%), intervertebral disc involvement (83.6%), paravertebral abscess (50.9%), disc abscess (49.6%), epidural abscess (43.3%), vertebra height change (22.1%), psoas abscess (22.0%), and abnormal vertebral accessory (10.2%). MR imaging of BS was categorized into three types. Type I: 57 (9.3%) patients; Type II: 526 (85.5%) patients, including IIa (26.5%), IIb (36.9%), and IIc (22.1%); Type IV: vertebral appendage type, 63 (10.2%) cases; Type III: 32 (5.2%) patients.

CONCLUSIONS

MRI features of multicenter data can provide theoretical support for diagnosing BS. MRI classification of BS can afford better help for clinical treatment and follow-up after clinical treatment.

The Need for Comprehensive Medical Management in Pyogenic Spondylodiscitis: A Review Article

The incidence of spontaneous or primary spondylodiscitis has been increasing over the years, affecting the aging population with multiple comorbidities. Several conditions influencing treatment outcomes stand out, such as diabetes mellitus, renal insufficiency, cardiovascular and respiratory dysfunction, and malnutrition. Due to these, the question arises regarding properly managing their current conditions and pre-existing disease states. Treatment plans must consider all concomitant comorbidities rather than just the infectious process. This can be done with the help of multidisciplinary teams to provide comprehensive care for patients with pyogenic spondylodiscitis. To date, there is no article regarding comprehensive medicine for spontaneous pyogenic spondylodiscitis; hence, this paper reviews the evidence available in current literature, recognizes knowledge gaps, and suggests comprehensive care for treating patients with spinal infections. Pre-requisites for implementing multidisciplinary teams include leadership, administrative support, and team dynamics. This group comprises an appointed leader, coordinator, and different subspecialists, such as orthopedic surgeons, infectious disease specialists, internists, rehabilitation doctors, psychiatrists, microbiologists, radiologists, nutritionists, pharmacologists, nurses, and orthotists working together with mutual trust and respect. Employing collaborative teams allows faster time for diagnosis and improves clinical outcomes, better quality of life, and patient satisfaction. Forefront communication is clear and open between all team members to provide holistic patient care. With these in mind, the need for employing multidisciplinary teams and the feasibility of its implementation emerges, showing a promising and logical path toward providing comprehensive care in managing multimorbid patients with pyogenic spondylodiscitis.

A retrospective review of gram-negative spinal infections in a single tertiary spinal centre over six years

Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

Methods

A retrospective review was performed of all gram-negative spinal infections (n = 32; median age 71 years; interquartile range 60 to 78), excluding surgical site infections, at a single centre between 2015 to 2020 with two- to six-year follow-up. Information regarding organism identification, antibiotic regime, and treatment outcomes (including clinical, radiological, and biochemical) were collected from clinical notes.

Results

All patients had comorbidities and/or non-spinal procedures within the previous year. Most infections affected lumbar segments (20/32), with Escherichia coli the commonest organism (17/32). Causative organisms were identified by blood culture (23/32), biopsy/aspiration (7/32), or intraoperative samples (2/32). There were 56 different antibiotic regimes, with oral (PO) ciprofloxacin being the most prevalent (13/56; 17.6%). Multilevel, contiguous infections were common (8/32; 25%), usually resulting in bone destruction and collapse. Epidural collections were seen in 13/32 (40.6%). In total, five patients required surgery, three for neurological deterioration. Overall, 24 patients improved or recovered with a mean halving of CRP at 8.5 days (SD 6). At the time of review (two to six years post-diagnosis), 16 patients (50%) were deceased.

Conclusion

This is the largest published cohort of gram-negative spinal infections. In older patients with comorbidities and/or previous interventions in the last year, a high level of suspicion must be given to gram-negative infection with blood cultures and biopsy essential. Early organism identification permits targeted treatment and good initial clinical outcomes; however, mortality is 50% in this cohort at a mean of 4.2 years (2 to 6) after diagnosis.

Surgery for Vertebral Osteomyelitis Lowers 1-Year Mortality and Failure Rates Compared with Nonsurgical Treatment: A Propensity-Matched Analysis

BACKGROUND

The aim of this study was to determine differences between patients who underwent surgical treatment and those who underwent nonsurgical treatment of vertebral osteomyelitis (VO) and to identify potential factors influencing treatment failure (death and/or recurrence within 1 year).

METHODS

We performed a retrospective analysis of clinical data prospectively collected from patients treated for VO between 2008 and 2020. The decision between surgical and nonsurgical treatment was made for each patient based on defined criteria. A 1:1 propensity score matching was performed to exclude confounders between the 2 treatments. Univariate and multivariable analyses were performed to identify potential risk factors for death and/or recurrence within the first year after VO diagnosis.

RESULTS

Forty-two patients (11.8%) were treated nonsurgically and 313 patients (88.2%) underwent surgery. A higher percentage of the surgically treated patients than the nonsurgically treated patients had an American Society of Anesthesiologists score of >2 (69.0% versus 47.5%; p = 0.007), and the thoracic spine was affected more often in the surgical group (30.4% versus 11.9%; p = 0.013). Endocarditis was detected significantly more often in the nonsurgically treated patients (14.3% versus 4.2%; p = 0.018). The recurrence rate was 3 times higher in the nonsurgically treated patients (16.7% versus 5.4%; p = 0.017), but this difference was no longer detectable after propensity matching. After matching, the nonsurgically treated patients showed an almost 7-fold higher 1-year mortality rate (25.0% versus 3.7%; p = 0.018) and an almost 3-fold higher rate of treatment failure (42.9% versus 14.8%; p = 0.022). Multivariable analysis revealed nonsurgical treatment and bacteremia to be independent risk factors for treatment failure.

CONCLUSIONS

In our matched cohort of patients with VO, surgical intervention resulted in a significantly lower rate of treatment failure (death and/or recurrence within 1 year) compared with nonsurgical intervention. Furthermore, nonsurgical treatment was an independent risk factor for treatment failure.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Culture-negative versus culture-positive in pyogenic spondylitis and analysis of risk factors for relapse

OBJECTIVES

This study aims to compare and analyze the clinical features, diagnosis, treatment and prognosis of culture-negative and culture-positive primary pyogenic spondylitis.

METHODS

In a retrospective analysis, 202 cases of adult primary pyogenic spondylitis with complete clinical data in our hospital from January 2013 to January 2020 were divided into two groups according to bacterial culture results: culture negative (n = 126) and culture positive (n = 76). We compare the clinical characteristics, diagnosis, treatment and prognosis of patients with different culture results.

RESULTS

The culture positive rate was 37.62% (76/202). There were no significant differences in age, gender, affected segment, spinal abscess, diabetes mellitus, course of disease, surgery, recurrence, and follow-up time between the two groups (p>.05). There were statistically significant differences in hospital admission erythrocyte sedimentation rate (ESR), admission C-reactive protein (CRP), admission white blood cell (WBC) count, discharge ESR, discharge CRP, ESR decline rate, CRP (p<.05). There were statistically significant differences in the rate of decline, hospitalization days, and body temperature ≥38 °C (p<.05). Higher CRP levels on admission, antibiotic treatment time <6 weeks, and body temperature ≥ 38 °C are independent risk factors for infection recurrence.

CONCLUSIONS

The culture-negative group's admission WBC, admission ESR, admission CRP, discharge ESR, discharge CRP, ESR decline rate, CRP decline rate, and hospital stay were lower than the culture positive group, the difference was statistically significant (p<.05). The independent risk factors for infection recurrence are higher CRP levels in hospital admission, antibiotic treatment time <6 weeks, and body temperature ≥ 38 °C.

Value of Spinal Infection Treatment Evaluation Score, Pola Classification, and Brighton Spondylodiscitis Score from Decision to Surgery in Patients with Spondylodiscitis: A Receiver-Operating Characteristic Curve Analysis

STUDY DESIGN

This was a retrospective study.

PURPOSE

This study aimed to assess the value of the Spinal Infection Treatment Evaluation (SITE) score, Brighton Spondylodiscitis Score (BSDS), and Pola classification to predict the need for surgical intervention in patients with spondylodiscitis.

OVERVIEW OF LITERATURE

Spondylodiscitis is a rare disease, and the prediction of its outcome is crucial in the decision-making process.

METHODS

All case records were assessed to extract information on the American Spinal Injury Association (ASIA), Visual Analog Scale (VAS), and Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores before and after surgery. The SITE score, Pola classification, and BSDS were recorded. The receiver-operating characteristic (ROC) curve analysis and the area under the curve (AUC) were applied to estimate the predictive ability of the scoring systems. Patients' satisfaction with surgery outcomes was evaluated using the VAS, ASIA, JOABPEQ, and Likert scale for quality-of-life evaluation.

RESULTS

In all 148 patients, case records were reviewed. The mean±standard deviation age of the patients was 54.6±14.7 years. Of these, 112 patients underwent surgery. The AUC scores were 0.86, 0.81, and 0.73 for the SITE score, BSDS, and Pola classification, respectively. In the comparison of the AUC of ROC curves, SITE score vs. BSDS showed a significantly greater AUC, 0.13 (Z =2.1, p =0.037); SITE score vs. Pola classification, 0.05 (Z =0.82, p =0.412); and Pola classification vs. BSDS, 0.08 (Z =1.22, p =0.219). The optimal cutoff score was 8.5 (sensitivity, 80.6%; specificity, 81.2%) for the SITE score and 9.5 (sensitivity, 52.8%; specificity, 83.0%) for the BSDS in the decision to surgery. VAS back pain and JOABPEQ subscales showed a significant difference when compared with preoperative scores. According to ASIA grading, none of the patients experienced neurological deterioration. Overall, patients' satisfaction was observed.

CONCLUSIONS

The findings suggest that the SITE score is a useful measure and helps clinicians make clinically sound decisions in patients with spondylodiscitis.

The importance of the bacterial spectrum in the clinical diagnostics and management of patients with spontaneous pyogenic spondylodiscitis and isolated spinal epidural empyema: a 20-year cohort study at a single spine center

BACKGROUND

Personalized clinical management of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) is challenging due to limited evidence of microbiologic findings and their clinical impact during the clinical course of the disease. We aimed to characterize clinico-microbiological and imaging phenotypes of SD and ISEE to provide useful insights that could improve outcomes and potentially modify guidelines.

METHODS

We performed chart review and collected data on the following parameters: bacterial antibiogram-resistogram, type of primary spinal infection, location of spinal infection, source of infection, method of detection, clinical complications (sepsis, septic embolism, and endocarditis), length of hospital and intensive care unit (ICU) stay, relapse rate, and disease-related mortality in patients with proven pyogenic SD and ISEE treated surgically in a university hospital in Germany between 2002 and 2022.

RESULTS

We included data from 187 patients (125 SD, 66.8% and 62 ISEE, 33.2%). Gram-positive bacteria (GPB) were overall more frequently detected than gram-negative bacteria (GNB) (GPB: 162, 86.6% vs. GNB: 25, 13.4%, p < 0.001). Infective endocarditis was caused only by GPB (GPB: 23, 16.5% vs. GNB: 0, 0.0%, p = 0.046). Methicillin-susceptible Staphylococcus aureus was the most frequently isolated strain (MSSA: n = 100, 53.5%), occurred more frequently in the cervical spine compared to other bacteria (OB) (MSSA: 41, 41.0% vs. OB: 18, 20.7%, p = 0.004) and was most frequently detected in patients with skin infection as the primary source of infection (MSSA: 26, 40.6% vs. OB: 11, 16.7%, p = 0.002). Streptococcus spp. and Enterococcus spp. (SE: n = 31, 16.6%) were more often regarded as the cause of endocarditis (SE: 8, 27.6% vs. OB: 15, 11.4%, p = 0.037) and were less frequently detected in intraoperative specimens (SE: 19, 61.3% vs. OB: 138, 88.5%, p < 0.001). Enterobacterales (E: n = 20, 10.7%) were identified more frequently in urinary tract infections (E: 9, 50.0% vs. OB: 4, 3.6%, p < 0.001). Coagulase-negative Staphylococci (CoNS: n = 20, 10.7%) were characterized by a lower prevalence of sepsis (CoNS: 4, 20.0% vs. OB: 90, 53.9%, p = 0.004) and were more frequently detected in intraoperative specimens (CoNS: 20, 100. 0% vs. OB: 137, 82.0%, p = 0.048). Moreover, CoNS-associated cases showed a shorter length of ICU stay (CoNS: 2 [1-18] days vs. OB: 6 [1-53] days, median [interquartile range], p = 0.037), and occurred more frequently due to foreign body-associated infections (CoNS: 8, 61.5% vs. OB: 15, 12.8%, p = 0.008). The presence of methicillin-resistant Staphylococcus aureus (MRSA) prolonged hospital stay by 56 [24-58] days and ICU stay by 16 [1-44] days, whereas patients with Pseudomonas aeruginosa spent only 20 [18-29] days in the hospital and no day in the ICU 0 [0-5] days.

CONCLUSIONS

Our retrospective cohort study identified distinct bacterial-specific manifestations in pyogenic SD and ISEE regarding clinical course, neuroanatomic targets, method of pathogen detection, and sources of infection. The clinico-microbiological patterns varied depending on the specific pathogens.

Evaluation of diagnostic criteria and choice of treatment tactics for patients with infectious spondylodiscitis based on a case series

Objective. To present a brief description of a series of clinical cases of infectious spondylodiscitis with an assessment of the used diagnostic criteria in terms of their influence on the choice of sanifying treatment tactics.

Material and Methods. A continuous retrospective study of 39 cases of spondylodiscitis was carried out. Level of evidence is IIIC. The level of ESR, serum C-reactive protein, the results of the study of biopsy materials, and CT and MRI data were evaluated. Criteria of neurological deficit, instability of the spinal motion segment, and recommendations for assessing the clinical and radiological severity of the disease were used to select the treatment tactics. Treatment success was defined as primary wound healing, absence of recurrent infection and/or death, and satisfaction with treatment according to the EQ-5D and EQ-VAS scales at a follow-up period of 22.5 months.

Results. The average age of patients was 57.4 years. Primary spondylodiscitis accounted for 82 %, the predominant localization of the pathological focus was the lumbar spine (56.4 %), and staphylococci were predominant etiologic agents (59.1 %). On average, the increase in ESR was 45 mm/h, C-reactive protein – 57 ng/l, and D-dimer – 1235 pg/ml. The level of pain before sanation according to the VAS scale was 6.79 points, after the operation it was 2.3 points (p < 0.05). Instability of the spinal motion segment according to the SINS scale was revealed in 36 cases, paravertebral abscess according to MRI – in 51.3 % of cases, and neurological deficit – in 38.5 % of cases. Severe spondylodiscitis according to the SponDT scale was noted in 53.8 %, moderate – in 43.6 %, and mild – in 2.6 % of patients. According to the clinical and radiological classification of infectious spondylodiscitis severity (SSC), grade I was present in 2 patients, grade II – in 21, and grade III – in 6. Compliance of the chosen treatment tactics with current recommendations was noted in 94,9 % of cases. Recurrence of infection was observed in 7.7 %; lethal outcome – in 5.1 %. Satisfaction with the quality of life according to EQ-5D was 0.74 points, and according to EQ-VAS – 73.88 points.

Conclusions. The integrated use of criteria for neurological deficit, instability of spinal motion segments, and severity of the disease according to the SponDT classification with the account of Pola’s recommendations on treatment tactics made it possible to choose the optimal treatment tactics and achieve satisfactory results in the sanation of patients with infectious spondylodiscitis.

Advances in diagnosis and management of atypical spinal infections: A comprehensive review

Atypical spinal infections (ASIs) of the spine are a challenging pathology to management with potentially devastating morbidity and mortality. To identify patients with atypical spinal infections, it is important to recognize the often insidious clinical and radiographic presentations, in the setting of indolent and smoldering organism growth. Trending of inflammatory markers, and culturing of organisms, is essential. Once identified, the spinal infection should be treated with antibiotics and possibly various surgical interventions including decompression and possible fusion depending on spine structural integrity and stability. Early diagnosis of ASIs and immediate treatment of debilitating conditions, such as epidural abscess, correlate with fewer neurological deficits and a shorter duration of medical treatment. There have been great advances in surgical interventions and spinal fusion techniques for patients with spinal infection. Overall, ASIs remain a perplexing pathology that could be successfully treated with early diagnosis and immediate, appropriate medical, and surgical management.

Recurrence rate after posterior percutaneous screw fixation without anterior debridement for pyogenic spondylitis compared with conservative treatment: a propensity score-matched analysis

PURPOSE

Previous studies have shown that percutaneous pedicle screw (PPS) posterior fixation without anterior debridement for pyogenic spondylitis can improve patient quality of life compared with conservative treatment. However, data on the risk of recurrence after PPS posterior fixation compared with conservative treatment is lacking. The aim of this study was to compare the recurrence rate of pyogenic spondylitis after PPS posterior fixation without anterior debridement and conservative treatment.

METHODS

The study was conducted under a retrospective cohort design in patients hospitalized for pyogenic spondylitis between January 2016 and December 2020 at 10 affiliated institutions. We used propensity score matching to adjust for confounding factors, including patient demographics, radiographic findings, and isolated microorganisms. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for recurrence of pyogenic spondylitis during the follow-up period in the matched cohort.

RESULTS

148 patients (41 in the PPS group and 107 in the conservative group) were included. After propensity score matching, 37 patients were retained in each group. PPS posterior fixation without anterior debridement was not associated with an increased risk of recurrence compared with conservative treatment with orthosis (HR, 0.80; 95% CI, 0.18-3.59; P = 0.77).

CONCLUSIONS

In this multi-center retrospective cohort study of adults hospitalized for pyogenic spondylitis, we found no association in the incidence of recurrence between PPS posterior fixation without anterior debridement and conservative treatment.

Predictive Performance of MRI for Antibiotic Treatment Failure of Pyogenic Vertebral Osteomyelitis: A Validation Study

INTRODUCTION

Intravenous antibiotics are the primary treatment of choice for pyogenic vertebral osteomyelitis (PVO). Surgical intervention is required when the initial antibiotic treatment fails but is often difficult to perform, especially in older adults with multiple comorbidities, because of the reduced physical activity. The size of the infection signal in the spinal bone on magnetic resonance imaging (MRI) at the time of diagnosis was reported to have a high predictive accuracy for antibiotic treatment failure. However, the sample size was too small for this result to be adopted in clinical practice. Thus, we conducted a validation study of the previous research using a larger sample size.

METHODS

We conducted a retrospective review of electronic medical records of patients admitted to the orthopedic department of a university hospital with a diagnosis of PVO between 2006 and 2021, and consecutively included patients without planned PVO surgery on admission and with a sagittal view of T1-weighted spinal MRI at the time of diagnosis. The index test was the percentage involvement of the affected areas in one motion segment on sagittal MRI. We also evaluated other MRI findings, such as bone destruction, segmental instability, epidural abscesses, and multiple sites for their predictive accuracy for antibiotic treatment failure.

RESULTS

A total of 82 participants were eligible for the analysis. The presence of ≥90% affected area of one motion segment had a sensitivity of 16.7% and a specificity of 70.3% for future antibiotic treatment failure, resulting in poor predictive performance, with positive (LR+) and negative likelihood ratios of 0.56 and 1.19, respectively. The area under the receiver operating characteristic curve for a 10% increase in the affected area was 0.48. Among the other MRI findings, the presence of bone destruction had a significantly higher predictive accuracy (LR+ 3.11, 95% confidence interval 1.30-7.42).

CONCLUSION

An infection signal ≥90% on a T1-weighted MRI of one spinal motion segment did not show sufficient predictive performance for antibiotic treatment failure. Spinal bone destruction had a mild-to-moderate predictive accuracy.

Evaluation of Classification Systems and Their Correlation With Clinical and Quality-of-life Parameters in Patients With Surgically Treated Spondylodiskitis

INTRODUCTION

Surgical classifications for spondylodiscitis (SD) typically include radiologic features and the status of neurologic impairment. Clinical factors such as preoperative pain, function/disability, overall quality of life (QoL), and risk of recurrence and mortality, which are necessary for a comprehensive assessment of SD and measurement of treatment success, are not considered. There is a lack of external validation of SD classifications. The aim of this study was to validate classifications of SD and to correlate these classifications with the above clinical factors.

METHODS

One hundred fourteen patients from a prospective SD register (2008-2020) with available imaging, preoperative neurologic status, backpain, function/disability data (Oswestry Disability Index and Core Outcome Measures Index), QoL data (Short Form 36, European Quality-of-life Questionnaire), and a 1-year follow-up were retrospectively classified according to Akbar, Homagk, and Pola classifications. Interrater reliability, correlation among classifications, and correlation between classifications and QoL were calculated.

RESULTS

Interrater reliability was κ = 0.83 for Akbar, κ = 0.94 for Homagk, and κ = 0.99 for Pola. The correlation of Akbar with Pola and Homagk was moderate (ρ s = 0.47; ρ s = 0.46) and high between Pola and Homagk (ρ s = 0.7). No notable correlation was observed between any of the classifications and preoperative Oswestry Disability Index, Core Outcome Measures Index, QoL, mortality, and recurrence within 1 year. Only a weak correlation was observed between Homagk and preoperative leg pain and back pain.

CONCLUSION

Available SD classifications have a very good interrater reliability and moderate-to-high correlation with each other but lack correlation with preoperative pain, function/disability, and overall QoL. Because these factors are important for a comprehensive assessment of SD in severity, decision making, and prognosis, they should be included in future SD classifications. This could allow for more comprehensive treatment algorithms.

LEVEL OF EVIDENCE

Level II. Diagnostic study = prospective cohort study; development of diagnostic criteria.

DATA AVAILABILITY

The data sets used and analyzed during this study are available from the corresponding author on reasonable request.

[Spondylodiscitis]

Spondylodiscitis is a severe infectious disease of the spine that affects the intervertebral discs and adjacent vertebrae. It can lead to nonspecific pain, limited mobility, and destruction of spinal structures. Various pathogens, such as bacteria, fungi, or parasites, can trigger the disease. An early diagnosis and targeted treatment are crucial to reduce the risk of serious complications. Magnetic resonance imaging (MRI) with contrast agent and blood tests are essential for the diagnosis and assessing the course of the disease. The treatment includes conservative and surgical approaches. Conservative treatment consists of a minimum 6‑week antibiotic course and immobilization of the affected area. Surgical interventions, along with several weeks of antibiotic therapy, are indicated for instabilities or complications in order to eliminate the infection focus and to restore spinal stability.

Clinical efficacy and imaging analysis for the surgical treatment of thoracolumbar infections in elderly patients: a retrospective study

Few reports have been conducted to comparing surgical results and safety evaluations between the different types of infections in geriatric patients with thoracolumbar infections. The aim of this study is to investigate the safety and efficacy of surgical treatment for thoracolumbar infections in elderly patients. 21 patients with pyogenic spondylodiscitis (PS) and 26 patients with tuberculous spondylodiscitis (TS) were enrolled in the study. All patients were treated using one-stage posterior debridement, decompression, and pedicle screw fixation. Comparison of operative safety parameters between the two groups. Clinical efficacy was evaluated using visual analogue scale (VAS) score, the American Spinal Injury Association (ASIA) grade, the short form (SF)-36 survey and Oswestry disability index (ODI) to determine patient quality of life pre- and post-operatively. Hospitalisation and intensive care unit duration in the PS group were significantly shorter than in the TS group (P < 0.05). The total incidence of post-operative complications for both groups was 44.7%. More complications occurred in the TS group, but the difference was not significant. The scores of VAS, ODI and SF-36 of all 47 patients were significantly improved compared with those before operation.The VAS and SF-36 scores (physical component) were significantly better in the PS group 6 months post-operatively, and the SF-36 (mental component) scores were significantly better in the PS group at the 1-year follow-up. Neurological status in both groups improved post-operatively, and 83% of patients reported satisfactory results based on the modified MacNab standard. Imaging results showed that bone graft fusion improved in both groups at 6 months, 1 year and at the final follow-up. One-stage posterior debridement, decompression, interbody fusion, and internal fixation can be considered a safe and effective method of treating spinal infections in the elderly. This method can improve nerve function, reconstruct spinal stability, and enhance the quality of life of elderly patients. Both PS and TS who underwent surgery achieve similar clinical and radiological results.

Management of Lumbar Pyogenic Spondylodiscitis in Germany: A Cross-Sectional Analysis of Spine Specialists

OBJECTIVE

The incidence of pyogenic spondylodiscitis is increasing, and the disease is associated with considerable morbidity, mortality, long-term healthcare utilization and societal costs. Disease-specific treatment guidelines are lacking and there is little consensus regarding optimal conservative and surgical management. This cross-sectional survey of German specialist spinal surgeons sought to determine practice patterns and degree of consensus regarding the management of lumbar pyogenic spondylodiscitis (LPS).

METHODS

An electronic survey covering provider information, diagnostic approaches, treatment algorithms, and follow-up care of patients with LPS was distributed to members of the German Spine Society.

RESULTS

Seventy-nine survey responses were included in the analysis. Magnetic resonance imaging is the diagnostic imaging modality of choice for 87% of respondents; 100% routinely measure C-reactive protein in suspected LPS and 70% routinely take blood cultures before therapy initiation; 41% believe that surgical biopsy to obtain microbiological diagnosis should be carried out in all cases of suspected LPS, whereas 23% believe that surgical biopsy should only be carried out when empirical antibiotic therapy proves ineffective; 38% believe an intraspinal empyema should always be surgically evacuated, regardless of spinal cord compression. The median intravenous antibiotic duration is 2 weeks. The median total duration of the antibiotic therapy (intravenous and oral) is 8 weeks. Magnetic resonance imaging is the preferred imaging modality for follow-up of both conservatively and operatively treated LPS.

CONCLUSIONS

There exists considerable variation of care in the diagnosis, management, and follow-up of LPS among German spine specialists with little agreement on key aspects of care. Further research is required to understand this variation in clinical practice and to enhance the evidence base in LPS.

Mortality, complication risks, and clinical outcomes after surgical treatment of spinal epidural abscess: a comparative analysis of patients aged 18-64 years, 65-79 years, and ≥ 80 years, with a 3-year follow-up

Spinal epidural abscess (SEA) with pyogenic vertebral osteomyelitis (PVO) is a rare illness with a steadily increasing incidence. However, comparative analyses of young and older patients with SEA are lacking. We aimed to compare the clinical course of patients aged 18-64 years, 65-79 years, and ≥ 80 years undergoing surgery for SEA. Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Ninety-nine patients aged 18-64 years, 45 patients aged 65-79 years, and 32 patients ≥ 80 years were enrolled. Patients ≥ 80 years presented with a poorer baseline history (9.2 ± 2.4), as indicated by the CCI, than their younger counterparts (18-74 years: 4.8 ± 1.6;6.5 ± 2.5; p < 0.001). Patients aged 65-79 years and 80 years had a significantly longer length of stay. In-hospital mortality was significantly higher in those aged ≥ 80 years compared to their younger counterparts (≥ 80 years, n = 3, 9.4% vs. 18-64 years, n = 0, 0.0%; 65-79 years, n = 0, 0.0%; p < 0.001), while no differences in 90-day mortality or 30-day readmission were observed. After surgery, a significant decrease in C-reactive protein levels and leukocytes and amelioration of motor scores were observed in all the groups. Of note, older age (> 65 years), presence of comorbidities, and poor preoperative neurological condition were significant predictors of mortality. Surgical management led to significant improvements in laboratory and clinical parameters in all age groups. However, older patients are prone to multiple risks, requiring meticulous evaluation before surgery. Nevertheless, the risk profile of younger patients should not be underestimated. The study has the limitations of a retrospective design and small sample size. Larger randomized studies are warranted to establish the guidelines for the optimal management of patients from every age group and to identify the patients who can benefit from solely conservative management.

2022 SPILF - Clinical Practice guidelines for the diagnosis and treatment of disco-vertebral infection in adults

These guidelines are an update of those made in 2007 at the request of the French Society of Infectious Diseases (SPILF, Société de Pathologie Infectieuse de Langue Française). They are intended for use by all healthcare professionals caring for patients with disco-vertebral infection (DVI) on spine, whether native or instrumented. They include evidence and opinion-based recommendations for the diagnosis and management of patients with DVI. ESR, PCT and scintigraphy, antibiotic therapy without microorganism identification (except for emergency situations), therapy longer than 6 weeks if the DVI is not complicated, contraindication for spinal osteosynthesis in a septic context, and prolonged dorsal decubitus are no longer to be done in DVI management. MRI study must include exploration of the entire spine with at least 2 orthogonal planes for the affected level(s). Several disco-vertebral samples must be performed if blood cultures are negative. Short, adapted treatment and directly oral antibiotherapy or early switch from intravenous to oral antibiotherapy are recommended. Consultation of a spine specialist should be requested to evaluate spinal stability. Early lifting of patients is recommended.

Clinical features of infectious spondylitis in patients with COVID-19

Objective. To  analyze the clinical features of the course of infectious spondylitis in patients with COVID-19.

Material and Methods. A continuous retrospective study was performed with the analysis of medical records of 52 patients with infectious spondylitis who were treated in 2021–2022. The patients were divided into two groups: the study group (n = 24) – with a history of a new coronavirus infection; and the control group (n = 28) – without coronavirus infection.

Results. The features of infectious spondylitis in patients with COVID-19 are the predominance of facultative anaerobic gram-negative flora in the focus of infection, a higher frequency of multilevel lesions, a tendency to increase the number of negative results of surgical treatment, and a chronic protracted course. At the same time, the course of infectious spondylitis associated with COVID-19 is accompanied by less destructive changes in the affected segment leading to a violation of the supporting function of the spine. Nevertheless, there is a statistically significant increase in the period of relief of the inflammatory process in the spine in these patients: 18.04 ± 3.84 weeks in the study group and 10.08 ± 2.34 weeks in the control group (Uemp < 240; p = 0.001).

Conclusion. The secondary infectious lesion of the spine against the background of a new coronavirus infection is caused by gram-negative pathogens in the vast majority of cases, proceeds without severe bone destruction, with a tendency to a chronic protracted course. Surgical treatment of COVID-associated spondylitis is associated with a higher risk of postoperative complications.

Outcomes of C-arm cone-beam CT-guided percutaneous procedures for thoracolumbar spondylodiscitis: a comparison between with and without intradiscal drainage

INTRODUCTION

Percutaneous intradiscal drainage had little established evidence to date. We assessed the outcomes of C-arm cone-beam CT-guided (CBCT-guided) procedures for spondylodiscitis and compare procedures with and without intradiscal drainage.

MATERIAL AND METHODS

A retrospective review was conducted on patients who underwent CBCT-guided procedures for spondylodiscitis with fluid collection in the intradiscal space between January 2010 and September 2021. Included patients were divided into two groups: with and without 'intradiscal drainage' (ID and non-ID, respectively).

RESULTS

A total of 87 patients with thoracolumbar discitis (mean age 73.4 ± 12.3 years, 35 females) were included. There was no significant difference in clinical outcomes between groups. Although insignificant, a subgroup analysis of patients with discitis and psoas abscess showed a higher infection control success rate (81% (17/21) vs 58% (7/12), p = .23) and faster median C-reactive protein improvement (CRP <3 mg/dL: 12 vs 42 days, p = .11, CRP <1 mg/dL: 27 vs 45 days, p = .097) of ID than of non-ID.

CONCLUSIONS

Findings did not clarify the role of intradiscal drainage when it was indicated in all cases of spondylodiscitis with fluid collection. Future studies with larger sample sizes of selected discitis cases are expected to demonstrate the superiority of intradiscal drainage.

Percutaneous Versus Open Pedicle Screw Fixation for Pyogenic Spondylodiscitis of the Thoracic and Lumbar Spine: Systematic Review and Meta-Analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

This meta-analysis aimed to compare percutaneous (PPS) versus open pedicle screw (OPS) fixation for treatment of thoracic and lumbar spondylodiscitis.

SUMMARY OF BACKGROUND DATA

Pyogenic spondylodiscitis of the thoracic and lumbar spine can produce instability, deformity, and/or neurological compromise. When medical treatment is unsuccessful, surgical treatment is indicated, with the conventional open approach the usual standard of care. However, percutaneous techniques can be advantageous in medically vulnerable patients.

MATERIALS AND METHODS

A literature search was performed using the PubMed, Web of Science, and Scopus databases, looking for comparative articles on pyogenic spondylodiscitis requiring surgical stabilization with pedicle screws. This systematic review is reported according to PRISMA guidelines.

RESULTS

From 215 articles initially identified, 7 retrospective studies were analyzed, encapsulating an overall sample of 722 patients: 405 male (56.1%) and 317 female (43.9%). The treatment modality was PPS fixation in 342 patients (47.4%) and OPS fixation in 380 (52.6%). For PPS, operating time was 29.75 minutes ( P <0.0001), blood loss 390.18 mL ( P <0.00001), postoperative pain 1.54 points ( P <0.00001), and length of stay 4.49 days ( P =0.001) less than with OPS fixation, and wound infection 7.2% ( P =0.003) less frequent. No difference in screw misplacement ( P =0.94) or loosening ( P =0.33) rates was observed.

CONCLUSION

Employing PPS fixation to treat pyogenic spondylodiscitis of the thoracic and lumbar spine is associated with significantly reduced operating time, blood loss, postoperative pain, length of stay, and rates of wound infection than OPS fixation, with no difference between the 2 treatments in rates of screw misplacement or screw loosening.

Long-Term Clinical and Radiologic Outcome Following Surgical Treatment of Lumbar Spondylodiscitis: A Retrospective Bicenter Study

BACKGROUND AND STUDY AIMS

 Spinal instrumentation for spondylodiskitis (SD) remains highly controversial. To date, surgical data are limited to relatively small case series with short-term follow-up data. In this study, we wanted to elucidate the biomechanical, surgical, and neurologic long-term outcomes in these patients.

MATERIAL AND METHODS

 A retrospective analysis from two German primary care hospitals over a 9-year period (2005-2014) was performed. The inclusion criteria were (1) pyogenic lumbar SD, (2) minimum follow-up of 1 year, and (3) surgical instrumentation. The clinical and radiologic outcome was assessed before surgery, at discharge, and at a minimum of 12 months of follow-up. Follow-up included physical examination, laboratory results, CT and MRI scans, as well as assessment of quality of life (QoL) using short-form health survey (SF-36) inventory, Oswestry Disability Questionnaire, and visual analog scale (VAS) spine score.

RESULTS

 Complete data were available in 70 patients (49 males and 21 females, with an age range of 67±12.3 years) with a median follow-up of 6.6 ± 4.2 years. Follow-up data were available in 70 patients after 1 year, in 58 patients after 2 years, and in 44 patients after 6 years. Thirty-five patients underwent posterior stabilization and decompression alone and 35 patients were operated on in a two-stage 360-degree interbody fusion with decompression. Pre- and postoperative angles of the affected motion segment were 17.6 ± 10.2 and 16.1 ± 10.7 degrees in patients with posterior instrumentation only and 21.0 ± 10.2 and 18.3 ± 10.5 degrees in patients with combined anterior/posterior fusion. Vertebral body subsidence was seen in 12 and 6 cases following posterior instrumentation and 360-degree instrumentation, respectively. Nonfusion was encountered in 22 and 11 cases following posterior instrumentation and 360-degree instrumentation, respectively. The length of hospital stay was 35.0 ± 24.5 days. Surgery-associated complication rate was 18% (12/70). New neurologic symptoms occurred in 7% (5/70). Revision surgery was performed in 3% (2/70) due to screw misplacement/hardware failure and in 3% (2/70) due to intraspinal hematoma. Although patients reported a highly impaired pain deception and vitality, physical mobility was unaffected and pain disability during daily activities was moderate.

CONCLUSION

 Surgical treatment of SD with a staged surgical approach (if needed) is safe and provides very good long-term clinical and radiologic outcome.

A new classification of spondylodiscitis: possibility of validation and multidisciplinary expert consensus

Objective. To perform validation study of the E. Pola classification (2017) and to assess expert consensus on the diagnosis and treatment of infectious lesions of the spine in the national professional community.

Material and Methods. A clinical and radiological database on 15 cases of infectious spondylitis, as well as the information about original article by Pola and a Russian translation of the classification and tactical tables from this article, were distributed to 408 orthopedic traumatologists, neurosurgeons and radiologists who have experience in treating patients with spinal pathology and whose data are available in the registers of the relevant professional associations of the Russian Federation. The coincidence/difference in the responses concerning the definition of lesion types and the choice of treatment tactics, as well as proposals for the use of classification were assessed.

Results. Answers were obtained from 37 respondents from 11 regions of the Russian Federation. The general interobserver agreement index (Fleiss kappa) for all types of spondylodiscitis was 0.388 (95 % CI 0.374–0.402), including for lesion types: type A – 0.480 (95 % CI 0.460–0.499, type B – 0.300 (95 % CI 0.281–0.320), and type C – 0.399 (95 % CI 0.380–0.419). Agreement levels were higher among radiologists (type A – 0.486, type B – 0.484, and type C – 0.477), orthopedic traumatologists (type A – 0.474, type B – 0.380, and type C – 0.479), and specialists with clinical experience less than 10 years (type A – 0.550, type B – 0.318, and type C – 0.437). The pooled data for all 12 lesion subtypes showed general poor agreement (k = 0.247, CI 0.240–0.253), satisfactory level was found for B3.2 type (k = 0.561, CI 0.542–0.581), good agreement (k > 0.61) was achieved between orthopedic traumatologists for type B3.2 and between radiologists for B3.1 and B3.2 lesion types. Respondents refused to use basic treatment options for type A in 15.1 %, type B in 7.5 % and type C in 3.2 % of answers, while indicating the need for interventions through anterior approach in 24.7 %, 43.0 % and 46.2 %, respectively. Limitations of the classification use depending on the localization and etiology of spondylitis were noted. Authors recommended taking into account the presence of systemic inflammatory response syndrome, mandatory CT scanning, clarification of spinal instability criteria, and the addition of anterior surgical interventions to the treatment algorithm.

Conclusion. The Pola classification of spondylodiscitis is currently considered the most successful for tactical algorithms and implementation in broad clinical practice for spondylodiscitis. However, at the stages of its clinical application, there is an unsatisfactory interobserver expert consensus on the types of lesions, and there are limitations related to the etiology, localization and severity of the disease. A modified classification taking into account the identified limitations and including anterior procedures in the tactical options is advisable.

Surgical Management of Spinal Epidural Abscess in Elderly Patients: A Comparative Analysis Between Patients 65-79 Years and ≥80 Years with 3-Year Follow-Up

BACKGROUND

Recently, the incidence of pyogenic vertebral osteomyelitis with spinal epidural abscess (SEA) has increased. However, the most appropriate surgical management remains debatable, especially for older patients. This study aimed to compare the clinical course in older patients aged between 65 and 79 years and those 80 years or older undergoing surgery for SEA.

METHODS

Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality of patients diagnosed with pyogenic vertebral osteomyelitis and SEA between September 2005 and December 2021 were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index.

RESULTS

We enrolled 45 patients aged 65-79 years and 32 patients ≥80 years. Patients ≥80 years had significantly higher rates of Charlson comorbidity index (9.2 ± 2.4) than younger patients (6.5 ± 2.5; P < 0.001). Arterial hypertension, renal failure, and dementia were significantly more prevalent in octogenarians (P < 0.05). Patients aged ≥80 years had a significantly longer length of hospitalization, while the intensive care unit stay was similar between groups. In-hospital mortality was significantly greater in those ≥80 years (n = 3, 9.4% vs. n = 0, 0.0%; P = 0.029), whereas no differences in 90-day mortality or 30-day readmission were observed. In the second-stage analysis, significant improvements in blood infection parameters and neurologic status were detected in both groups. Of adverse events, pneumonia occurred significantly more frequently in patients aged ≥80 years.

CONCLUSIONS

Surgical management leads to significant improvements in both laboratory and clinical parameters in older patients. Nevertheless, a personalized medical approach is mandatory in frail patients, especially octogenarians. A clear discussion regarding the potential risk is unambiguously recommended.

The Percutaneous Endoscopic Lumbar Debridement and Irrigation Drainage Technique for the First-Stage Treatment of Spontaneous Lumbar Spondylodiscitis: A Clinical Retrospective Study

Background

Minimally invasive or open surgery is contentious in the treatment of spondylodiscitis, therefore finding a balance between the two is urgently needed. In this study, we propose a new treatment paradigm for treating spontaneous lumbar spondylodiscitis by percutaneous endoscopic lumbar debridement and irrigation drainage (PELDID). Then, the Pola classification was used to guide subsequent treatment.

Methods

From November 2017 to April 2019, this study collected data on 16 patients with lumbar spondylodiscitis who were surgically treated utilizing this treatment paradigm in our department. Clinical effectiveness was determined using the visual analogue scale (VAS), the Oswestry Disability Index (ODI), the MOS 36-item short-form health survey (SF-36), and Kirkaldy-Willis criteria.

Results

All 16 patients completed the treatment using the above paradigm and were followed up for 28.13 ± 10.15 months. The preoperative Pola classification is as follows: 7 cases of type A, 3 cases of type B, and 6 cases of type C. After the first-stage surgery, the evaluation results of Pola classification were as follows: 8 cases of type A, 8 cases of type B, and 0 cases of type C. Four patients received second-stage surgery with internal fixation through the paravertebral multifidus space approach and intervertebral bone graft fusion through the transforaminal approach, and the reoperation rate was 25% (4/16 cases). The Visual analogue scale (VAS), Oswestry Disability Index (ODI), and SF-36 score all improved significantly from 2.43 ± 0.89 to 0.18 ± 0.40, from 77.31% ± 11.15%to 16.93% ± 5.45%, and from 18.34 ± 7.47 to 80.3 ± 15.36. The CRP and ESR decreased dramatically from 49.61 ± 48.84 to12.50 ± 12.18 and from 65.56 ± 26.89 to 29.68 ± 20.68. There were no recurrences of infection in our study.

Conclusions

The paradigm of the first-stage PELDID technique combined with the Pola classification system to guide the second-stage treatment for spontaneous spondylodiscitis is a novel and effective strategy for treating spontaneous spondylodiscitis.

Treatment Failure in Vertebral Osteomyelitis: Is it All About Staphylococcus aureus ?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim was to compare the influence of 2 common vertebral osteomyelitis (VO) causing pathogens on treatment failure within the first year of diagnosis.

SUMMARY OF BACKGROUND DATA

VO is mainly caused by Staphylococcus aureus (SA), while enterococci and streptococci (ENST) are also responsible for a significant proportion of VO, particularly in elderly patients. Data on VO caused by SA show a tendency for worse outcome, whereas data on VO caused by ENST are scarce. For this purpose, our study compares characteristics of patients with VO caused by SA or ENST in order to analyze risk factors for treatment failure.

METHODS

We conducted a retrospective monocentric study including VO patients from 2008 to 2020. Primary outcome was treatment failure defined as death or relapse within 1 year (T1). We compared patients diagnosed with VO caused by Staphylococcus aureus including MRSA to patients diagnosed with VO caused by Enterococcus and Streptococcus species, which were combined into one group. Polymicrobial infections were excluded. We employed multiple logistic regression analysis to adjust for confounding. To account for moderation, the model was repeated with an included interaction term.

RESULTS

Data of 130 VO patients (SA=95; ENST=35) were available at T1. Treatment failure occurred in 37% of SA patients and 23% of ENST patients. On multivariate analysis SA [odds ratio (OR): 3.12; 95% confidence interval (CI): 1.09-10.53; P =0.046], Charlson comorbidity index (OR: 1.31; 95% CI: 1.11-1.58; P =0.002) and infectious endocarditis (IE; OR: 4.29; 95% CI: 1.23-15.96; P =0.024) were identified as independent risk factors for treatment failure.

CONCLUSION

In our cohort every third patient with VO caused by SA or ENST dies within 1 year. Our findings indicate that patients with VO caused by SA, concomitant IE and/or a high Charlson comorbidity index score may be at elevated risk for treatment failure. These findings can be used to individualize patient care and to direct clinical surveillance. This could include echocardiography evaluating for the presence of IE in patients with VO caused by gram-positive pathogens.

WHICH PROBLEMATICS IN THA AFTER ACETABULAR FRACTURES: EXPERIENCE OF 38 CASES

BACKGROUND

Within a timeframe of 8 years (2008-2016), 38 patients have undergone total hip replacement surgery for coxarthrosis or aseptic necrosis secondary to acetabulum fractures.

MATERIALS AND METHODS

The study included 27 males and 11 females between 42 and 70 years of age, all of whom came from other institutions. The follow-up period ranged between a minimum of 4.6 and a maximum of 9.7 years.

RESULTS

At the final follow-up, all patients were evaluated using the Merle D'Aubigne and Pastel model. Optimal results were found in all the cases. Three patients benefited from surgical revisitation with implant exchange following infection and one/two state reimplatation at seven, fourtheen et twenty-seven months respectively. Two patients benefited from cotyle revision due to chronic instability of the implant.

CONCLUSIONS

The scope of the study was to present all the possible surgical difficulties that can come up with prosthetic implants. More particularly, hip implants after acetabulum fractures qualifies as a "difficult primary implant".

The Brighton Spondylodiscitis Score Does Not Accurately Predict the Need for Surgery: A Retrospective Cohort Study in New Zealand

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Despite pyogenic spondylodiscitis potentially conferring significant morbidity, there is no consensus on optimal treatment. The Brighton Spondylodiscitis Score (BSDS) was developed to identify patients who would likely fail conservative management and therefore benefit from earlier surgical intervention. In this study, we attempt external validation of the BSDS.

METHODS

We carried out a retrospective review of all patients treated at our institution, 2010-2016, for pyogenic spondylodiscitis. 91 met inclusion criteria and 40 progressed to require surgical intervention. The BSDS was calculated for each patient allowing stratification into low-, moderate- and high-risk groups. Calibration and discrimination was assessed with ROC curve analysis and calibration plot.

RESULTS

Area under the curve (AUC) was 0.469 (0.22-0.71) in our external validation, compared with AUC 0.83 and 0.71 (CI 0.50-0.88) in the original study and test populations respectively. Only 60% of patients in the high-risk group required surgery, 50% in the moderate, and 38% of the low indicating poor calibration and predictive accuracy. Operative intervention was not higher overall in our cohort (44% vs. 32%, p = 0.14). We found greater rates of bacteraemia, more distal infection, and more advanced MRI findings in our cohort. The incidence of spondylodiscitis in our region is higher (4/100 000/year).

CONCLUSION

We failed to externally validate the BSDS in our population which is likely a result of unique population characteristics and the inherently variable pathology associated with spondylodiscitis. Clinicians must be cautious in adopting treatment algorithms developed in other health care systems that may comprise significantly different patient and pathogen characteristics.

Da Vinci robot-assisted laparoscopic retroperitoneal debridement for lumbar septic spondylodiscitis: A two-case report

The anterior approach is one of the widely used surgical treatments for lumbar spondylodiscitis, but it has the disadvantages of large trauma and a high incidence of complications. Our experiences suggested that the laparoscopic retroperitoneal approach could be effective to overcome those disadvantages of the anterior approach. Herein, we report two cases of successfully treated lumbar pyogenic spondylodiscitis using a robot-assisted laparoscopic retroperitoneal approach. The technique utilizes a robot that allows a laparoscopic retroperitoneal approach while offering excellent high-definition images of three-dimensional vision. After the operation, both patients achieved good formation and fusion of the vertebrae. Preliminary evidence suggests that the robot-assisted laparoscopic retroperitoneal approach may be feasible for the treatment of lumbar spondylodiscitis.

Pyogenic spinal infections in patients with chronic liver disease: illustrative case and systematic review

BACKGROUND

Pyogenic spinal infections (PSIs) are a group of uncommon but serious infectious diseases that are characterized by inflammation of the endplate–disc unit. PSIs are considered more prevalent and aggressive among patients with chronic immunocompromised states. Association between PSIs and liver disease has not been systematically analyzed. The authors performed a systematic review to study baseline characteristics, clinical presentation, and mortality of patients with PSI in the setting of chronic liver disease.

OBSERVATIONS

The authors presented the case of a 72-year-old female patient with chronic liver disease who presented with severe low back pain and bilateral lower weakness. Imaging studies showed T10–11 spondylodiscitis. The patient received decompression and fusion surgery with partial neurological improvement. The authors performed a systematic literature search of spondylodiscitis and liver disease, and eight published articles met the studies inclusion and exclusion criteria. These studies featured a total of 144 patients, of whom 129 met inclusion criteria (mean age, 60.5 years, range 40 to 83 years; 62% males). Lumbar infection was the most common report (67%), with Staphylococcus aureus (48%) as the main causative microorganism. Neurological compromise was present in 69% of patients. Surgical intervention occurred in 70.5% of patients, and the average duration of antibiotic treatment was 69.4 days. Postoperative complication rate was 28.5%, with a 30- and 90-day mortality of 17.2% and 24.8%, respectively.

LESSONS

Pyogenic spondylodiscitis in patients with liver disease was associated with a high rate of neurological compromise, postoperative complications, and mortality.

Decompression only versus fusion in octogenarians with spinal epidural abscesses: early complications, clinical and radiological outcome with 2-year follow-up

Despite increased life expectancy due to health care quality improvements globally, pyogenic vertebral osteomyelitis (PVO) treatment with a spinal epidural abscess (SEA) remains challenging in patients older than 80 years. We aimed to assess octogenarians for PVO prevalence with SEA and compare after-surgery clinical outcomes of decompression and decompression and instrumentation. A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Over 16 years, 35 patients aged ≥80 years with PVO and SEA were identified. Eighteen patients underwent surgical decompression (“decompression group”), and 17 underwent surgical decompression with instrumentation (“instrumentation group”). Both groups had a CCI >6 (mean±SD, 8.9±2.1 vs. 9.6±2.7, respectively; p=0.065). Instrumentation group patients had a significantly longer hospital stay but no ICU stay. In-hospital and 90-days mortality rates were similar in both groups. The mean follow-up was 26.6±12.4 months. No further surgeries were performed. Infection levels and neurological status were improved in both groups at discharge. At the second-stage analysis, significant improvements in the blood infection parameters and the neurological status were detected in the decompression group. Octogenarians with PVO and SEA have a high adverse events risk after surgical procedures. Surgical decompression might contribute to earlier clinical recovery in older patients. Thus, the surgical approach should be discussed with patients and their relatives and be carefully weighed.

[Current practice of empiric antibiotic treatment for spondylodiscitis]

Hintergrund und Fragestellung

Bei der pyogenen Spondylodiszitis gewinnen Infektionen mit Koagulase-negativen Staphylokokken zunehmend an Bedeutung. Eine empirische Antibiose ist insbesondere bei Patienten mit schweren oder progredienten neurologischen Ausfällen sowie hämodynamischer Instabilität und im Falle von kulturnegativen Spondylodiszitiden notwendig. Ob es in Deutschland einheitliche, an das Resistenzprofil angepasste Standards der empirische Antibotikatherapie gibt, ist unklar.

Studiendesign und Untersuchungsmethoden

Es wurde an deutschen Universitäts- und berufsgenossenschaftlichen Kliniken, jeweils in den Fachbereichen Orthopädie und Unfallchirurgie, eine Umfrage zur empirischen Antibiotikatherapie bei pyogener Spondylodiszitis durchgeführt. Die Umfrageergebnisse wurden auf das Resistenzprofil der Erreger von 45 Spondylodiszitispatienten, die zwischen 2013 und 2020 in unserer Klinik behandelt wurden, angewandt. Dadurch wurden potenzielle Sensibilitäts- und Resistenzraten für die angegebenen antibiotischen Therapien errechnet.

Ergebnisse

Von den 71 angefragten Kliniken antworteten insgesamt 44 (62,0 %). Sechzehn verschiedene Antibiotikatherapien wurden als jeweiliger Standard berichtet. Darunter wurden 14 verschiedene Kombinationstherapien als Therapiestandard angegeben. Die am häufigsten angegebenen empirischen Substanzen, nämlich Amoxicillin-Clavulansäure oder Ampicillin/Sulbactam (29,5 %) und Cephalosporine (18,2 %) zeigten in Bezug auf das zuvor veröffentliche Resistenzprofil hohe potenzielle Resistenzraten von 20,0 % bzw. 35,6 %. Die höchsten potenziellen Sensibilitätsraten wurden durch die Kombinationen Vancomycin + Ampicillin/Sulbactam (91,1 % sensible Erreger), Vancomycin + Piperacillin/Tazobactam (91,1 % sensible Erreger) und Ampicillin/Sulbactam + Teicoplanin (95,6 % sensible Erreger) erreicht. Eine dieser Kombinationen wurde von drei Kliniken (6,8 %) als Standard angegeben.

Schlussfolgerung

Die deutschlandweite Umfrage zur empirischen Antibiose bei pyogener Spondylodiszitis hat eine große Heterogenität der Standardtherapien ergeben. Eine Kombination aus einem Breitspektrum-β-Laktam-Antibiotikum mit einem zusätzlichen Glykopeptidantibiotikum kann sinnvoll sein.

Clinical Characteristics of Patients with Pyogenic Vertebral Osteomyelitis and Concurrent Infections and Their Clinical Outcomes

Patients with pyogenic vertebral osteomyelitis (PVO) often develop concurrent infections, and a significant number of these patients show rapid deterioration in their medical condition, leading to mortality without PVO-related structural instability or neurological deficits. To improve clinical outcomes, we investigated the clinical presentation and treatment outcomes of patients with PVO and concurrent infections. This study included 695 patients with PVO, of which 175 (25%) had concurrent infections and 520 (75%) did not. The clinical characteristics of the two groups were compared, and multivariable analysis was performed to identify the association between concurrent infections and clinical outcomes. Patients with concurrent infections were older and had more comorbidities than those without. Moreover, there were significant intergroup differences in the anatomical involvement of PVO, and patients with concurrent infections had a higher number of regions involved more frequently than those without concurrent infections (15% vs. 6%). In contrast, patients with concurrent infections showed a lower degree of focal invasiveness, including a lower incidence of posterior abscess (47% vs. 59%; p = 0.008) and fewer neurological impairments according to the American Spinal Injury Association grade (p < 0.001) than those without concurrent infections. The causative organisms also differed significantly between the two groups, and patients with concurrent infections had a greater proportion of Gram-negative infections (31% vs. 16%, respectively) and a smaller proportion of methicillin-resistant S. aureus infections than those without concurrent infections (6% vs. 24%). Consequently, their clinical outcomes were significantly different, and patients with concurrent infections showed lower recurrence and higher mortality rates. We investigated the 1-year recurrence and mortality rates and their 95% confidence intervals according to the types of concurrent infections and their time of diagnosis and found variations in these parameters. Our results, based on a large number of patients, can be practically used as a reasonable reference to warn clinicians of the clinical risks of concurrent infections in patients with PVO and to help predict their clinical outcomes.

Antibiotic-loaded calcium sulfate beads in spinal surgery for patients with spondylodiscitis: a clinical retrospective study

Background

Various surgical techniques for treating spondylodiscitis have been proposed, but the optimal surgical treatment remains controversial. In this study, we propose a new procedure that is implanting antibiotic-loaded calcium sulfate (CS) beads into the disc after debridement using the Quadrant channel combined with percutaneous fixation through a single-stage posterolateral approach for the treatment of spondylodiscitis. Thus, the purpose of this study is to assess the safety and efficacy of this procedure.

Methods

This study collected the data of 32 patients with spine spondylodiscitis and was surgically treated in our department from July 2015 to August 2020. The Demographic data included age, gender, involved segment, and complications were collected. The intra-operative details, results of culture, functional outcome, radiologic outcome, and length of hospital stay, laboratory examination were recorded.

Results

The mean age of the 32 patients was 61.1 ± 9.7 years old. The mean operative time was 135.0 ± 30.6 minutes, and the mean blood loss was 243.4 ± 92.1 ml. The positive rate of culture was 72%. The mean Visual analogue scale (VAS) and Oswestry Disability Index (ODI) score significantly improved from 7.5 to 1.6 and from 65% to 10%. Cobb angle was significantly improved and could be maintained at final follow-up. New bone formation was observed in all patients. There were no recurrences of infection in our study.

Conclusions

The posterolateral debridement and percutaneous fixation combined with antibiotic-loaded calcium sulfate beads filling are effective in the treatment of spondylodiscitis in terms of infection control, early mobilization, and recovery.

Non-specific spondylodiscitis: a new perspective for surgical treatment

PURPOSE

Pyogenic spondylodiscitis is a relatively rare spinal disease; non-specific spondylodiscitis (NSS) cases are increasing. This study aims to identify if changes of inflammatory markers under antibiotic therapy can be used to determine which NSS patients can benefit from surgical indication earlier than others.

METHODS

Two groups of patients with NSS were examined. Group A underwent surgery, while Group B was treated conservatively. Group B was also subdivided in patients undergoing antibiotic therapy for > 6 weeks (B1) and < 6 weeks (B2). Groups were compared for age, gender, BMI, blood levels of ESR and CRP and VAS scale.

RESULTS

There were no differences (P = 0.06) in reduction in ESR at 4 weeks between two main groups. A reduction in CRP, with < 2.7 mg/dl at 4 weeks, was observed in Group A (P = 0.01). Comparing Group B1 to B2, a reduction (P = 0.0001) in VAS, ESR and CRP at 4 weeks was observed in Group B2. It was possible to isolate the pathogen in 52.8% of Group B, without any differences on VAS, ESR and CRP values and on length of the antibiotic therapy.

CONCLUSIONS

The surgical treatment should be considered for patients who, after 4 weeks of conservative therapy, do not show a reduction in the ESR < 50 mm/h and of the CRP < 2.7 g/dl. The comparison between groups underwent surgically and those treated conservatively showed a reduction in the CRP at 4 weeks and better VAS for pain at 3 months in Group A.

An inter- and intra-rater agreement assessment of a novel classification of pyogenic spinal infections

PURPOSE

Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification.

METHODS

Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (wκ) to establish the inter- and intra-observer agreement.

RESULTS

The inter-observer agreement was substantial considering the main categories (wκ = 0.77; 0.71-0.82), but moderate considering the subtypes (wκ = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (wκ = 0.65; 0.59-0.71), and moderate considering the subtypes (wκ = 0.58; 0.54-0.63).

CONCLUSION

The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate.

The Hamburg Spondylodiscitis Assessment Score (HSAS) for Immediate Evaluation of Mortality Risk on Hospital Admission

(1) Background: Patients with spondylodiscitis often present with unspecific and heterogeneous symptoms that delay diagnosis and inevitable therapeutic steps leading to increased mortality rates of up to 27%. A rapid initial triage is essential to identify patients at risk for a complicative disease course. We therefore aimed to develop a risk assessment score using fast available parameters to predict in-hospital mortality of patients admitted with spondylodiscitis. (2) Methods: A retrospective data analysis of 307 patients with spondylodiscitis recruited from 2013 to 2020 was carried out. Patients were grouped according to all-cause mortality. Via logistic regression, individual patient and clinical characteristics predictive of mortality were identified. A weighted sum score to estimate a patient's risk of mortality was developed and validated in a randomly selected subgroup of spondylodiscitis patients. (3) Results: 14% of patients with spondylodiscitis died during their in-hospital stay at a tertiary center for spinal surgery. Univariate and logistic regression analyses of parameters recorded at hospital admission showed that age older than 72.5 years, rheumatoid arthritis, creatinine > 1.29 mg/dL and CRP > 140.5 mg/L increased the risk of mortality 3.9-fold, 9.4-fold, 4.3-fold and 4.1-fold, respectively. S. aureus detection increased the risk of mortality by 2.3-fold. (4) Conclusions: The novel Hamburg Spondylodiscitis Assessment Score (HSAS) shows a good fit identifying patients at low-, moderate-, high- and very high risk for in hospital mortality on admission (AUC: 0.795; p < 0.001). The implementation of the HSAS into clinical practice could ease identification of high-risk patients using readily available parameters alone, improving the patient's safety and outcome.

Treatment Guideline for Patients with Native Culture-negative Pyogenic Vertebral Osteomyelitis

BACKGROUND

With the development of evidence-based guidelines for the diagnosis and antibiotic treatment of patients with pyogenic vertebral osteomyelitis, various nonsurgical and surgical treatment strategies have achieved favorable results. However, sufficient administration of appropriate antibiotics is a prerequisite for treatment success, which cannot be guaranteed in patients with culture-negative pyogenic vertebral osteomyelitis. Unfortunately, previous studies on culture-negative pyogenic vertebral osteomyelitis were limited by small patient groups, short follow-up periods, varied treatment protocols, and inconsistently defined clinical endpoints.

QUESTIONS/PURPOSES

Among patients treated according to our center's treatment protocol for culture-negative pyogenic vertebral osteomyelitis, which included patients treated without surgery, with surgery but without spinal instrumentation, as well as patients treated with instrumented surgery, (1) what proportion of patients in each treatment group experienced recurrence (or persistence) of infection, complications of treatment, and death; and (2) what factors were independently associated with recurrent or persistent infection after treatment under this algorithm?

METHODS

This was a retrospective evaluation of a treatment protocol in use at one center from 2008 to 2020. During that time, we treated 183 patients for culture-negative pyogenic vertebral osteomyelitis. The diagnosis was based on clinical, laboratory, and radiological features excluding disease that presents similar features to pyogenic vertebral osteomyelitis. For those patients, our protocol included three possible approaches: nonsurgical treatment, including the use of empirical antibiotics (nonoperative group, n = 82); spinal decompression without instrumentation (noninstrumented group, n = 41); and spinal decompression with instrumentation (instrumented group, n = 60). The indications for each treatment during the period remained relatively consistent. Nonsurgical treatment including empirical antibiotics was applied to all patients according to the specified antibiotic protocol. Spinal decompression without instrumentation was employed when a patient presented substantial or aggravating neurologic deficits or intractable pain from an abscess. Instrumentation was added in patients with mechanical instability before or after spinal decompression. Minimum follow-up to be included in this study was 1 year, and 91% (252 of 277) of patients were accounted for at that time, with no differential loss to follow-up among the study groups (12, five, and four patients missing from the three groups, respectively, at 1 year). Chart review was performed to ascertain the proportion of patients in each group who experienced recurrence, complications, and death. Factors associated with recurrence were assessed across the entire cohort using a multivariable logistic model. We analyzed 1-year recurrence and mortality rates using the Kaplan-Meier method, and their 95% confidence intervals were calculated using the method by Hosmer and Lemeshow.

RESULTS

At 1 year, the recurrence-free survival rate was 87% (95% confidence interval 78% to 93%) in the nonoperative group, 87% (95% CI 72% to 94%) in the noninstrumented group, and 91% (95% CI 80% to 96%) in the instrumented group. The proportion of patients who experienced a major medical complication in each group was 12% (10 of 82), 10% (4 of 41), and 8% (5 of 60), respectively. At 1 year, the survival rate with patient death as the endpoint was 95% (95% CI 88% to 98%) in the nonoperative group, 95% (95% CI 82% to 99%) in the noninstrumented group, and 97% (95% CI 87% to 99%) in the instrumented group. After controlling for potentially confounding variables including age, medical comorbidities, and anatomical involvement of infection, the following factors were independently associated with increased odds of infection recurrence or persistence: higher Charlson Comorbidity Index (CCI) score (odds ratio 1.6 per point on the CCI [95% CI 1.2 to 2.1]; p = 0.004) and the presence of a psoas abscess (OR 4.7 [95% CI 1.6 to 13.9]; p = 0.005).

CONCLUSION

Among patients with negative initial nonoperative culture results, spinal decompression and abscess drainage can be used in those with substantial or aggravating neurological deficits or intractable pain caused by an abscess, while additional early spinal instrumentation can be applied upon consideration of their medical comorbidities and the presence of a psoas abscess when mechanical instability is present before or after the spinal decompression. Reasonable clinical results can be expected, regardless of the results from subsequent operative cultures. However, our study results should be replicated by other centers, and further studies that consider individual differences such as bone mineral density and include patients with previous spinal instrumentation or recurrent infection should be performed to establish a more comprehensive treatment protocol.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

MORPHOLOGICAL ASPECT OF PYOGENIC SPINAL EPIDURAL ABSCESSES. PART I

ABSTRACT Background: Pyogenic Spinal Epidural Abscess (PSEA) is difficult to diagnose and can have devastating consequences. Magnetic Resonance Imaging (MRI) has high sensitivity and specificity, which are further increased with the use of contrast. There are several classifications of vertebral infectious processes, with emphasis on spondylodiscitis. Objective: To analyze the morphological parameters and their reproducibility; and to analyze different resonance imaging sequences. Methods: Using an image database, a morphological classification of PSEA was planned, with five parameters: Region (R), indicating the upper and lower limits of the abscess; Location (U), indicating whether the abscess is anterior or posterior within the canal; Compromise (C), meningeal or content of the structures; Association (A), discitis, osteomyelitis or both; and Perivertebral (P), anterior, lateral or posterior extravertebral abscess. The first three parameters give an idea of the volume of the PSEA, while the last two give the related infectious foci. Thirty-five cases were analyzed using Kappa’s coefficient. Results: The global intra- and interobserver reproducibility was Kappa 0.81. The results for each parameter were as follows: R=0.95, U=0.92, C=0.66, A=0.70 and P=0.80. The first three give a notion of volume and the last two relate to the presence of vertebral infectious foci outside the canal. T2 weighted MRI with contrast was found to be the most effective imaging sequence. Conclusion: The morphological classification is simple to use, with excellent reproducibility. The parameters with the highest reproducibility were region and location, with values >0.92. The addition of gadolinium contrast increased the sensitivity of the diagnosis; the use of sagittal and axial images in T2-MRI was the most sensitive imaging sequence. Evidence Level III; Original.