Impact of the localization on disease course and clinical management in spondylodiscitis

Clinical and surgical outcome in patients with cervical spondylodiscitis-a single-center retrospective case series of 24 patients

Objective

Cervical spondylodiscitis is a rare pathology, with an incidence of 0.5-2.5 per 100,000 population, posing significant potential risks. This type of infection can lead to neurological impairment in up to 29% of patients. Radical surgical debridement of the infected segment, fusion, and an intravenous antibiotic regimen remains the gold standard in most spine centers. This study aimed to analyze the surgical outcome in a tertiary spine center based on disease severity.

Methods

In this study, we retrospectively included all patients diagnosed with cervical spondylodiscitis and treated at the University Hospital Augsburg between January 2017 and May 2022. We collected and analyzed baseline parameters on clinical presentation with symptoms, laboratory parameters, radiological appearance, and surgical parameters such as type of approach and implant, as well as neurological and radiological outcomes. Descriptive statistics were performed using SPSS, and relevant correlations were examined using the t-test for independent samples and the chi-square test.

Results

Twenty-four patients (9%) with cervical spondylodiscitis were identified. Twenty-two (92%) surgically treated patients were subdivided into the complicated discitis group (n = 14, 64%) and the uncomplicated discitis group (n = 8, 36%). Seventeen patients (71%) presented with sepsis on admission, 17 patients (71%) were diagnosed with epidural abscess on primary imaging, and 5 patients (21%) had more than one discitis lesion at a distant spinal segment. The presence of epidural abscess was significantly associated with systemic sepsis (OR = 6.2; p = 0.03) and myelopathy symptoms (OR = 14.4; p = 0.00). The most frequently detected specimen was a multisensitive Staphylococcus aureus (10 patients, 42%). Six patients (25%) died after a median of 20 days despite antibiogram-accurate therapy, five of whom were diagnosed with a complicated type of discitis. The follow-up data of 15 patients (63%) revealed permanent neurological damage in 9 patients (38%). Notably, the surgical approach was a significant factor for revision surgery (p = 0.008), as three out of five (60%) ventrodorsal cases with complicated discitis were revised.

Conclusion

Cervical spondylodiscitis represents a severe infectious disease that is often associated with permanent neurological damage or a fatal outcome, despite adequate surgical and antibiotic treatments. Complicated types of discitis may require a more challenging surgical and clinical course.

Midterm survival and risk factor analysis in patients with pyogenic vertebral osteomyelitis: a retrospective study of 155 cases

Background

Pyogenic vertebral osteomyelitis (VO) represents a clinical challenge and is linked to substantial morbidity and mortality. This study aimed to examine mortality as well as potential risk factors contributing to in-hospital mortality among patients with VO.

Methods

This retrospective analysis involved patients receiving treatment for VO at University Regensburg in Germany from January 1, 2000, to December 3, 2020. It included in-hospital mortality rate, comorbidities and pathogens. Patients were identified using ICD-10 diagnosis codes: M46.2, M46.3, M46.4, and M46.5. Kaplan-Meier probability plots and odds ratios (OR) for mortality were calculated.

Results

Out of the total cohort of 155 patients with VO, 53 patients (34.1%) died during a mean follow-up time of 87.8 ± 70.8 months. The overall mortality was 17.2% at one year, 19.9% at two years and 28.3% at five years. Patients with congestive heart failure (p = 0.005), renal disease (p < 0.001), symptoms of paraplegia (p = 0.029), and sepsis (p = 0.006) demonstrated significantly higher overall mortality rates. In 56.1% of cases, pathogens were identified, with Staphylococcus aureus (S. aureus) and other unidentified pathogens being the most common. Renal disease (OR 1.85) and congestive heart failure (OR 1.52) were identified as significant risk factors.

Conclusion

Early assessment of the specific risk factors for each patient may prove beneficial in the management and treatment of VO to reduce the risk of mortality. These findings demonstrate the importance of close monitoring of VO patients with underlying chronic organ disease and early identification and treatment of sepsis. Prioritizing identification of the exact pathogens and antibiotic sensitivity testing can improve outcomes for patients in this high-risk group.

Brucellar, Pyogenic, and Tuberculous Spondylodiscitis at Tertiary Hospitals in Saudi Arabia: A Comparative Retrospective Cohort Study

Introduction

Spondylodiscitis is rare yet the most common form of spinal infection. It is characterized by inflammation of the intervertebral disk space and adjacent vertebral body. In Western countries, the incidence of spondylodiscitis is increasing. Clinical outcomes most commonly reported in the literature are the 1-year mortality rate (range, 6%-12%) and neurologic deficits.

Methods

This multicenter retrospective cohort study assessed patients diagnosed with infectious spondylodiscitis who received treatment at King Abdulaziz Medical City in Riyadh and Jeddah, Saudi Arabia. All enrolled patients were ≥18 years old and were diagnosed per radiologic and microbiological findings and clinical manifestations between January 2017 and November 2021.

Results

This study enrolled 76 patients with infectious spondylodiscitis, with a median age of 61 years. All patients presented with back pain for a median 30 days. Patients were stratified into 3 groups based on the causative pathogen: brucellar spondylodiscitis (n = 52), tuberculous spondylodiscitis (n = 13), and pyogenic spondylodiscitis (n = 11). All laboratory data and biochemical markers were not significantly different. However, C-reactive protein, erythrocyte sedimentation rate, and white blood cells were significantly different in the pyogenic spondylodiscitis group, with medians of 121 mg/dL (P = .03), 82 mmol/h (P = .04), and 11.2 × 109/L (P = .014), respectively.

Conclusions

Back pain is a common clinical feature associated with infectious spondylodiscitis. The immense value of microbiological investigations accompanied with histologic studies in determining the causative pathogen cannot be emphasized enough. Treatment with prolonged intravenous antimicrobial therapy with surgical intervention in some cases produced a cure rate exceeding 60%.

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.

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.

BMP use in the surgical treatment of pyogenic spondylodiscitis: Is it safe?

OBJECTIVE

Use of BMP in the setting of infection remains controversial. We examined the safety and effectiveness of BMP in the surgical treatment of pyogenic spondylodiscitis and compared patients who have been treated with or without BMP during surgery.

METHODS

57 patients who have undergone surgery for pyogenic spondylodiscitis after presenting to a tertiary Spine referral institution between 2011 and 2020 were included. 18 underwent surgery alone without BMP and 39 underwent surgery with BMP. Outcomes were compared between the two groups, including re-operations, infection recurrences, BMP- related complications and radiological fusion.

RESULTS

The cohort comprised 41 males (71.9%) with a mean age 63.7 +/- 13.3 years. Surgical indications include instability (n = 18), pain (n = 4), neurological deficit (n = 15) and sepsis or failure of non-operative management (n = 20). In the group who underwent surgery without BMP, there were two cases of re-operation for infection recurrence (11.1%) and three cases of cage subsidence; 80% achieved definitive and probable fusion. In the group who underwent surgery with BMP, there were three cases of re-operation for infection recurrence (7.7%), three cases of cage subsidence and one case of BMP- related radiculitis; 96.5% achieved definitive and probable fusion.

CONCLUSIONS

The use of BMP in the surgical treatment of pyogenic spondylodiscitis did not confer an increased risk of infection recurrence, revision surgery or radiculitis. BMP can be a useful and safe adjunct in surgical intervention for pyogenic spondylodiscitis.

Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis

Establishing a multidisciplinary approach regarding the treatment of spondylodiscitis and analyzing its effect compared to a single discipline approach. 361 patients diagnosed with spondylodiscitis were included in this retrospective pre-post intervention study. The treatment strategy was either established by a single discipline approach (n = 149, year 2003–2011) or by a weekly multidisciplinary infections conference (n = 212, year 2013–2018) consisting of at least an orthopedic surgeon, medical microbiologist, infectious disease specialist and pathologist. Recorded data included the surgical and antibiotic strategy, complications leading to operative revision, recovered microorganisms, as well as the total length of hospital and intensive care unit stay. Compared to a single discipline approach, performing the multidisciplinary infections conference led to significant changes in anti-infective and surgical treatment strategies. Patients discussed in the conference showed significantly reduced days of total antibiotic treatment (66 ± 31 vs 104 ± 31, p < 0.001). Moreover, one stage procedures and open transpedicular screw placement were more frequently performed following multidisciplinary discussions, while there were less involved spinal segments in terms of internal fixation as well as an increased use of intervertebral cages instead of autologous bone graft (p < 0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most frequently recovered organisms in both patient groups. No significant difference was found comparing inpatient complications between the two groups or the total in-hospital stay. Implementation of a weekly infections conference is an effective approach to introduce multidisciplinarity into spondylodiscitis management. These conferences significantly altered the treatment plan compared to a single discipline approach. Therefore, we highly recommend the implementation to optimize treatment modalities for patients.