Comparative outcomes of operative relative to medical management of spondylodiscitis accounting for frailty status at presentation

Conservative versus early surgical treatment in the management of pyogenic spondylodiscitis: a systematic review and meta-analysis

Spondylodiscitis is the commonest spine infection, and pyogenic spondylodiscitis is the most common subtype. Whilst antibiotic therapy is the mainstay of treatment, some advocate that early surgery can improve mortality, relapse rates, and length of stay. Given that the condition carries a high mortality rate of up to 20%, the most effective treatment must be identified. We aimed to compare the mortality, relapse rate, and length of hospital stay of conservative versus early surgical treatment of pyogenic spondylodiscitis. All major databases were searched for original studies, which were evaluated using a qualitative synthesis, meta-analyses, influence, and regression analyses. The meta-analysis, with an overall pooled sample size of 10,954 patients from 21 studies, found that the pooled mortality among the early surgery patient subgroup was 8% versus 13% for patients treated conservatively. The mean proportion of relapse/failure among the early surgery subgroup was 15% versus 21% for the conservative treatment subgroup. Further, it concluded that early surgical treatment, when compared to conservative management, is associated with a 40% and 39% risk reduction in relapse/failure rate and mortality rate, respectively, and a 7.75 days per patient reduction in length of hospital stay (p < 0.01). The meta-analysis demonstrated that early surgical intervention consistently significantly outperforms conservative management in relapse/failure and mortality rates, and length of stay, in patients with pyogenic spondylodiscitis.

An Assessment of the Safety of Surgery and Hardware Placement in de-novo Spinal Infections. A Systematic Review and Meta-Analysis of the Literature

OBJECTIVES

Primary objectives were outcomes comparison of instrumented surgery used for de-novo spinal infections in terms of infection recurrence, reoperations, primary failure, mortality, and length of stay relative to non-instrumented surgery. Secondary objectives were outcomes for surgical and non-surgical treatment of de-novo spinal infections regarding recurrence of infection, mortality, quality of life, and length-of-stay.

METHODS

A systematic literature review was performed using the PubMed database. Studies comparing outcome variables of patients with de-novo spinal infections (DNSI) treated with and without instrumentation and surgical versus non-surgical treatment were included. Studies primarily focusing on epidural abscesses or non-de-novo infections were excluded. A meta-analysis was performed for infection recurrence, reoperation, primary treatment failure, mortality, and quality-of-life parameters.

RESULTS

A total of 17 retrospective studies with 2.069 patients met the inclusion criteria. 1.378 patients received surgical treatment with or without instrumentation; 676 patients were treated non-surgically. For the comparison of instrumented to non-instrumented surgery Odds-Ratios were .98 (P = .95) for infection recurrence, .83 (P = .92) for primary failure, .53 (P = .02) for mortality and .32 (P = .05) for reoperation. For the comparison of non-surgical to surgical treatment, Odds-Ratios were .98 (P = .95) for infection recurrence, and 1.05 (P = .89) for mortality.

CONCLUSION

Available data support that instrumented surgery can be performed safely without higher rates of infection recurrence or primary failure and lower reoperation and mortality rates compared to nonsurgical treatment for DNSI. Furthermore, spine surgical treatment may generally be performed without higher risk of infection recurrence and mortality and better quality-of-life outcomes compared to generic non-surgical treatment.

Spondylodiscitis in Geriatric Patients: What Are the Issues?

STUDY DESIGN

Review article.

OBJECTIVES

A review of literature on the treatment of pyogenic spondylodiscitis in geriatric patients was performed with the aim to give an overview about these special patients and a recommendation on necessary diagnostics as well as conservative and operative treatment options.

METHODS

A systematic computerized literature search was done by the spondylodiscitis working group of the German Society for Orthopedics and Trauma Surgery.

RESULTS

Spondylodiscitis has an increasing incidence by age with a peak at 75 years or older. The 1-year mortality without an appropriate treatment is with 15 to 20% extremely high. Pathogen detection is the essential diagnostic step and the basis for a sufficient antibiotic treatment. Geriatric patients have initially less elevated inflammatory parameters. Compared to younger patients. They have a longer length of hospital stay and take longer for CRP normalization. Even the outcome between conservative and operative treatment is comparable after one year. Patients with spinal instability, immobilizing pain, epidural abscess, and newly emerged neurological deficits should be considered for operative treatment.

CONCLUSIONS

The treatment of geriatric patients with pyogenic spondylodiscitis must take into account that these patients usually have multiple comorbidities. The main goals are resistance-based antibiotics and the shortest possible time of immobilization of the patient.

Continuous NPWT Regulates Fibrosis in Murine Diabetic Wound Healing

Scarring is associated with significant morbidity. The mechanical signaling factor yes-associated protein (YAP) has been linked to Engrailed-1 (En1)-lineage positive fibroblasts (EPFs), a pro-scarring fibroblast lineage, establishing a connection between mechanotransduction and fibrosis. In this study, we investigate the impact of micromechanical forces exerted through negative pressure wound therapy (NPWT) on the pathophysiology of fibrosis. Full-thickness excisional dorsal skin wounds were created on diabetic (db/db) mice which were treated with occlusive covering (control) or NPWT (continuous, −125 mmHg, 7 days; NPWT). Analysis was performed on tissue harvested 10 days after wounding. NPWT was associated with increased YAP (p = 0.04) but decreased En1 (p = 0.0001) and CD26 (p < 0.0001). The pro-fibrotic factors Vimentin (p = 0.04), α-SMA (p = 0.04) and HSP47 (p = 0.0008) were decreased with NPWT. Fibronectin was higher (p = 0.01) and collagen deposition lower in the NPWT group (p = 0.02). NPWT increased cellular proliferation (p = 0.002) and decreased apoptosis (p = 0.03). Western blotting demonstrated increased YAP (p = 0.02) and RhoA (p = 0.03) and decreased Caspase-3 (p = 0.03) with NPWT. NPWT uncouples YAP from EPF activation, through downregulation of Caspace-3, a pro-apoptotic factor linked to keloid formation. Mechanotransduction decreases multiple pro-fibrotic factors. Through this multifactorial process, NPWT significantly decreases fibrosis and offers promising potential as a mode to improve scar appearance.

The measurements of frailty and their possible application to spinal conditions: a systematic review

BACKGROUND CONTEXT

Frailty is associated with an increased risk of postoperative adverse events (AEs) within the surgical spine population. Multiple frailty tools have been reported in the surgical spine literature. However, the applicability of these tools remains unclear.

PURPOSE

Primary objective is to appraise the construct, feasibility, objectivity, and clinimetric properties of frailty tools reported in the surgical spine literature. Secondary objectives included determining the applicability and the most sensitive surgical spine population for each tool.

STUDY DESIGN

Systematic Review.

PATIENT SAMPLE

Studies reporting the use of a clinical frailty tool with a defined methodology in the adult surgical population (age ≥18 years).

OUTCOME MEASURES

Postoperative adverse events (AEs) including mortality, major and minor morbidity, length of stay (LOS), unplanned readmission and reoperation, admission to the Intensive Care Unit (ICU), and adverse discharge disposition; postoperative patient-reported outcomes (health-related quality of life (HRQoL), functional, cognitive, and symptomatic); radiographic outcomes; and postoperative frailty trajectory.

METHODS

This systematic review was registered with PROSPERO: CRD42019109045. Publications from January 1950 to December 2020 were identified by a comprehensive search of PubMed, Ovid, and Embase, supplemented by manual screening. Studies reporting and validating a frailty tool in the surgical spine population with a measurable outcome were included. Each tool and its clinimetric properties were evaluated using validated criteria and definitions. The applicability of each tool and its most sensitive surgical spine population was determined by panel consensus. Bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

47 studies were included in the final qualitative analysis. A total of 14 separate frailty tools were identified, in which 9 tools assessed frailty according to the cumulative deficit definition, while 4 instruments utilized phenotypic or weighted frailty models. One instrument assessed frailty according to the comprehensive geriatric assessment (CGA) model. Twelve measures were validated as risk stratification tools for predicting postoperative AEs, while 1 tool investigated the effect of spine surgery on postoperative frailty trajectory. The modified frailty index (mFI), 5-item mFI, adult spinal deformity frailty index (ASD-FI), FRAIL Scale, and CGA had the most positive ratings for clinimetric properties assessed.

CONCLUSIONS

The assessment of frailty is important in the surgical decision-making process. Cumulative deficit and weighted frailty instruments are appropriate risk stratification tools. Phenotypic tools are sensitive for capturing the relationship between spinal pathology, spine surgery, and prehabilitation on frailty trajectory. CGA instruments are appropriate screening tools for identifying health deficits susceptible to improvement and guiding optimization strategies. Studies are needed to determine whether spine surgery and prehabilitation are effective interventions to reverse frailty.

Which frailty scales for patients with adult spinal deformity are feasible and adequate? A systematic review

BACKGROUND CONTEXT

Frailty as a concept is not yet fully understood, and is not the same as comorbidity. It is associated with an increased risk of adverse events and mortality after surgery, which makes its preoperative assessment significant. Despite its relevance, it still remains unclear which scales are appropriate for use in patients with spinal pathology.

PURPOSE

To evaluate the feasibility and measurement properties of frailty scales for spine patients, specifically with adult spinal deformity (ASD), and to propose adequate scales for primary triage to prevent surgery in too frail patients and for preoperative assessment to modify patients' condition and surgical plans.

STUDY DESIGN/SETTING

Systematic review.

METHODS

Systematic search was performed between 2010 and 2021 including terms relating to spinal disorders, frailty scales, and methodological quality. Characteristics of the studies and frailty scales and data describing relation to treatment outcomes were extracted. The risk of bias was determined with the QAREL score.

RESULTS

Of the 1993 references found, 88 original studies were included and 23 scales were identified. No prospective interventional study was found where the preoperative frailty assessment was implemented. Predictive value of scales for surgical outcomes varied, dependent on spinal disorders, type of surgeries, patients' age and frailty at baseline, and outcomes. Seventeen studies reported measurement properties of eight scales but these studies were not free of bias. In 30 ASD studies, ASD-Frailty Index (ASD-FI, n=14) and 11-item modified Frailty Index (mFI-11, n=11) were most frequently used. These scales were mainly studied in registry studies including young adult population, and carry a risk of sample bias and make their validity in elderly population unclear. ASD-FI covers multidisciplinary concepts of frailty with 40 items but its feasibility in clinical practice is questionable due to its length. The Risk Analysis Index, another multidisciplinary scale with 14 items, has been implemented for preoperative assessment in other surgical domains and was proven to be feasible and effective in interventional prospective studies. The FRAIL is a simple questionnaire with five items and its predictive value was confirmed in prospective cohort studies in which only elderly patients were included.

CONCLUSIONS

No adequate scale was identified in terms of methodological quality and feasibility for daily practice. Careful attention should be paid when choosing an adequate scale, which depends on the setting of interest (eg triage or preoperative work-up). We recommend to further study a simple and predictive scale such as FRAIL for primary triage and a comprehensive and feasible scale such as Risk Analysis Index for preoperative assessment for patients undergoing spine surgery, as their adequacy has been shown in other medical domains.

Life Expectancy Is Poor in Patients with Diffuse Idiopathic Skeletal Hyperostosis-Related Pyogenic Vertebral Osteomyelitis

Introduction

Pyogenic vertebral osteomyelitis (PVO) is an uncommon but life-threatening infectious disease. Diffuse idiopathic skeletal hyperostosis (DISH) is an age-related disorder and sometimes problematic in terms of spinal instability or high mortality, especially in cases of DISH-related fracture. Meanwhile, no reports have focused on the impact of DISH on the clinical outcomes after treatment for PVO. We hypothesized that PVO occurring at DISH-related segments might contribute to poor clinical results or high mortality rates. The purpose of this study was to investigate the impact of DISH on mortality after treatment for PVO in a retrospective cohort study.

Methods

This study involved patients who were hospitalized and treated for PVO at a single institution. DISH-related PVO was defined as PVO within a segment ossified by DISH or PVO at the neighboring intervertebral level of the segment ossified by DISH. Differences in mortality between patients with DISH-related and non-DISH-related PVO were investigated.

Results

This study included 55 patients. DISH-related PVO was observed in 13 patients. The mortality rate was significantly higher in patients with DISH-related PVO than in those with non-DISH-related PVO (62% and 23%, respectively; p=0.016). Propensity score-adjusted analysis showed that DISH-related PVO was an independent risk factor for mortality (adjusted hazard ratio, 2.79; p=0.034). The survival probability was significantly shorter in patients with DISH-related PVO than in those with non-DISH-related PVO (p=0.006). PVO in which the intravertebral body was the center of involvement was significantly more common in DISH-related PVO than in non-DISH-related PVO (38% and 5%, respectively; p=0.006).

Conclusions

DISH-related PVO was associated with a higher mortality rate and shorter life expectancy than non-DISH-related PVO. Similar to advanced age, PVO at the segment ossified by DISH should be recognized as a risk factor for mortality when choosing the optimal treatment strategy.