1
|
Alavi SMA, Petri F, Mahmoud OK, Igwilo-Alaneme R, El Zein S, Nassr AN, Gori A, Berbari EF. Culture-Negative Native Vertebral Osteomyelitis: A Narrative Review of an Underdescribed Condition. J Clin Med 2024; 13:5802. [PMID: 39407862 PMCID: PMC11477431 DOI: 10.3390/jcm13195802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Revised: 09/24/2024] [Accepted: 09/25/2024] [Indexed: 10/20/2024] Open
Abstract
The incidence of culture-negative NVO (CN-NVO) cases is increasing, presenting significant diagnostic and therapeutic challenges due to the inability to isolate causative organisms with conventional microbiological methods. Factors influencing the diagnosis of CN-NVO include prior antimicrobial therapy, low pathogen burden, fastidious or intracellular organisms, technical issues, and non-infectious mimickers. Diagnosis often relies on imaging modalities like magnetic resonance imaging (MRI) and computed tomography (CT)-guided biopsy, though these methods can sometimes fail to yield positive microbiological results. Advanced diagnostic tools, such as polymerase chain reaction (PCR), metagenomic next-generation sequencing (mNGS), and cell-free DNA analysis, may be necessary to identify the pathogen. The causative pathogen cannot be isolated in some patients, among which an empirical antimicrobial therapy should be initiated. This narrative review discusses the management, monitoring, surgical indications, and outcomes for patients with CN-NVO.
Collapse
Affiliation(s)
| | - Francesco Petri
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN 55905, USA; (F.P.); (O.K.M.); (R.I.-A.); (S.E.Z.)
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco, “L. Sacco” University Hospital, 20157 Milan, Italy;
| | - Omar K. Mahmoud
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN 55905, USA; (F.P.); (O.K.M.); (R.I.-A.); (S.E.Z.)
| | - Rita Igwilo-Alaneme
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN 55905, USA; (F.P.); (O.K.M.); (R.I.-A.); (S.E.Z.)
| | - Said El Zein
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN 55905, USA; (F.P.); (O.K.M.); (R.I.-A.); (S.E.Z.)
| | - Ahmad N. Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Andrea Gori
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco, “L. Sacco” University Hospital, 20157 Milan, Italy;
- Centre of Multidisciplinary Research in Health Science (MACH), University of Milan, 20122 Milan, Italy
| | - Elie F. Berbari
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN 55905, USA; (F.P.); (O.K.M.); (R.I.-A.); (S.E.Z.)
| |
Collapse
|
2
|
Gao S, Hu Y, Li H, Mamat F, Xun C, Sheng W. One-Stage Surgical Management for Cervical Pyogenic Spondylodiscitis by Anterior Debridement, Reconstruction, and Instrumentation: A Single-Center Experience. World Neurosurg 2024:S1878-8750(24)01526-2. [PMID: 39242024 DOI: 10.1016/j.wneu.2024.08.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/28/2024] [Accepted: 08/29/2024] [Indexed: 09/09/2024]
Abstract
OBJECTIVE Surgical treatment is an effective strategy for cervical pyogenic spondylodiscitis (CPS). However, the optimal surgical approach is uncertain. This study was conducted to evaluate the clinical efficacy of debridement, reconstruction, and instrumentation via the anterior-only approach for CPS. METHODS We retrospectively collected the data of patients with CPS who underwent one-stage anterior debridement, reconstruction, and instrumentation from January 2013 to December 2022. The surgical duration and blood loss volume were analyzed. The Frankel grading classification was used to evaluate the improvement in neurological function. The visual analog scale and Japanese Orthopaedic Association scores were used to evaluate neck pain and functional recovery. The radiological parameters of regional lordosis angle and C2-C7 Cobb angle were used to evaluate the recovery of cervical alignment. C-reactive protein and erythrocyte sedimentation rate were evaluated to assess the control of infection. RESULTS Totally, 32 patients were eligible. The surgical duration was 118.9 ± 14.3 minutes, and the blood loss volume was 88.4 ± 42.7 mL. Significant improvements in the Frankel grading were observed in patients with neurological deficits. The visual analog scale and Japanese Orthopaedic Association scores significantly improved postoperatively and during follow-up (P < 0.01). The regional lordosis angle significantly increased from 4.0° ± 6.6° preoperatively to 8.4° ± 5.8° at the final follow-up (P < 0.01). The C2-C7 Cobb angle increased from 11.1° ± 7.1° preoperatively to 13.8° ± 7.2° at the final follow-up (P < 0.01). Bony fusion occurred in all patients. C-reactive protein and erythrocyte sedimentation rate significantly decreased postoperatively and returned to normal during follow-up. CONCLUSIONS One-stage debridement, reconstruction, and instrumentation via the anterior approach is an effective surgical strategy for CPS. In addition to surgery, targeted and prolonged antibiotic therapy is of crucial importance.
Collapse
Affiliation(s)
- Shutao Gao
- The First Affiliated Hospital of Xinjiang Medical University, Urmuqi, China
| | - Yukun Hu
- The First Affiliated Hospital of Xinjiang Medical University, Urmuqi, China
| | - Haonan Li
- The First Affiliated Hospital of Xinjiang Medical University, Urmuqi, China
| | - Fulati Mamat
- The First Affiliated Hospital of Xinjiang Medical University, Urmuqi, China
| | - Chuanhui Xun
- The First Affiliated Hospital of Xinjiang Medical University, Urmuqi, China
| | - Weibin Sheng
- The First Affiliated Hospital of Xinjiang Medical University, Urmuqi, China.
| |
Collapse
|
3
|
Chiu YC, Yang SC, Kao YH, Tu YK. Interim Use of Antibiotic-Loaded Cement Spacer for Patients with Infected Cervical Fusion. World Neurosurg 2024; 184:e511-e517. [PMID: 38316175 DOI: 10.1016/j.wneu.2024.01.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE The management of postoperative deep infection after anterior cervical discectomy and fusion (ACDF) remains challenging for spine surgeons. Our institution uses handmade antibiotic-loaded cement spacers to treat these complex cases. This study aimed to determine the efficacy and feasibility of this treatment. METHODS This study included 4 patients with deep cervical spine infections after ACDF who underwent our treatment between March 2012 and January 2022. Patients' laboratory data, visual analog scale scores, comorbidities, complications, and neurological status were recorded. Their clinical conditions were also evaluated based on the Neck Disability Index, Japanese Orthopaedic Association score, and Odom criteria. RESULTS Infection eradication was achieved in all patients after treatment. The average preoperative visual analog scale score was 7.5 (range: 7-8); this decreased to 1.25 (range: 1-2) at 1 year postoperatively. None of the patients experienced severe complications, such as neurological deterioration or bone graft dislodgement. The Neck Disability Index improved from a preoperative value of 54% (range: 48-60%) to 6% (range: 4-8%) at 1 year postoperatively. The Japanese Orthopaedic Association score improved from a preoperative score of 10.25 (range: 10-11)-14.75 (range: 14-16) at 1 year postoperatively. All patients achieved excellent outcomes based on Odom criteria at 1 year postoperatively. CONCLUSIONS Good clinical outcomes were achieved in this study. Although 2-stage surgery is required, this technique could be an alternative for patients with postoperative deep infection after ACDF.
Collapse
Affiliation(s)
- Yen-Chun Chiu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Chinese Medicine for Post Baccalaureate, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Shih-Chieh Yang
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - Yu-Hsien Kao
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| |
Collapse
|
4
|
Lenga P, Gülec G, Kiening K, Unterberg AW, Ishak B. Surgical management of ventrally located cervical epidural abscess: A comparative analysis between patients aged 18-64 years and ≥65 years. World Neurosurg X 2024; 22:100344. [PMID: 38455241 PMCID: PMC10918261 DOI: 10.1016/j.wnsx.2024.100344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 02/21/2024] [Indexed: 03/09/2024] Open
Abstract
Background We aimed to compare the clinical course of patients aged 18-65 years and ≥65years who underwent anterior cervical discectomy and fusion (ACDF) or corpectomy for ventrally located CSEA. Methods Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Results A total of 35 and 26 patients aged 18-64 and ≥ 65 years, respectively who were diagnosed with ventrally located CSEA were included. The overall mean age was 63.9 ± 3.2 years, with a predominance of the male sex (n = 43/61, 70.5%). Patients aged ≥65 years presented with significantly higher rates of comorbidities (10.3 ± 2.8), as indicated by the CCI, than their younger counterparts (18-64 years: 6.2 ± 2.6; p < 0.001). No differences in the surgical approach or characteristics were observed among the groups. Notably, patients aged ≥65 years had a significantly longer intensive care unit as well as overall hospital stay. In-hospital and 90-day mortality were similar across both groups. Following both types of surgery, a significant improvement was observed in the blood infection parameters and neurological status at discharge compared with the baseline measurements. Older age, higher rates of comorbidities, and higher grades of disability were significant predictors for mortality. Conclusions Emergency surgical evacuation should be undertaken for CSEA in the presence of acute neurological deterioration regardless of the age. Factors, such as age, comorbidities, and neurological status on admission appear to be important predictors of disease outcomes. However, the risk profile of younger patients should not be underestimated.
Collapse
Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Gelo Gülec
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
5
|
Hijazi MM, Siepmann T, El-Battrawy I, Schröttner P, Podlesek D, Schackert G, Juratli TA, Eyüpoglu IY, Filis A. 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. BMC Infect Dis 2024; 24:39. [PMID: 38166791 PMCID: PMC10762996 DOI: 10.1186/s12879-023-08946-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Mido Max Hijazi
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Timo Siepmann
- Department of Neurology, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ibrahim El-Battrawy
- Department of Cardiology, Bergmannsheil University Hospital, Ruhr University Bochum, Bürkle de la Camp-Platz 1, 44789, Bochum, Germany
| | - Percy Schröttner
- Institute for Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
- Institute for Microbiology and Virology, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Dino Podlesek
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Tareq A Juratli
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ilker Y Eyüpoglu
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Andreas Filis
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| |
Collapse
|
6
|
Treffy RW, Laing B, Eraky AM, Shabani S. Cervical spine spondylodiscitis: Review of literature on current treatment strategies. Heliyon 2023; 9:e17875. [PMID: 37483708 PMCID: PMC10359881 DOI: 10.1016/j.heliyon.2023.e17875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/15/2023] [Accepted: 06/29/2023] [Indexed: 07/25/2023] Open
Abstract
Infections of the spine are an ever-increasing health concern requiring an often complex and prolonged treatment that can lead to significant morbidity. Of particular interest is the cervical spine where there is an increase rate of post-infectious deformity, secondary neurological deficits and substantially higher rates of associated morbidity and mortality than the thoracic or lumbar spine. In this review, we explore the diagnosis and treatment of spondylodiscitis with particular focus on the cervical spine.
Collapse
Affiliation(s)
- Randall W. Treffy
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Brandon Laing
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Akram M. Eraky
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA
| |
Collapse
|
7
|
ACDF versus corpectomy in octogenarians with cervical epidural abscess: early complications and outcomes with 2 years of follow-up. Acta Neurochir (Wien) 2023; 165:875-882. [PMID: 36629954 PMCID: PMC10068646 DOI: 10.1007/s00701-023-05488-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/01/2023] [Indexed: 01/12/2023]
Abstract
PURPOSE Cervical spinal epidural abscess (CSEA) is a rare condition, manifesting as rapid neurological deterioration and leading to early neurological deficits. Its management remains challenging, especially in patients older than 80 years. Therefore, we aimed to compare the clinical course and determine morbidity and mortality rates after anterior cervical discectomy and fusion (ACDF) versus corpectomy in octogenarians with ventrally located CSEA at two levels. METHODS In this single-center retrospective review, we obtained the following from electronic medical records between September 2005 and December 2021: patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality rate. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). RESULTS Over 16 years, 15 patients underwent ACDF, and 16 patients underwent corpectomy with plate fixation. Between the two groups, patients who underwent corpectomy had a significantly poorer baseline reserve (9.0 ± 2.6 vs. 10.8 ± 2.7; p = 0.004) and had a longer hospitalization period (16.4 ± 13.1 vs. 10.0 ± 5.3 days; p = 0.004) since corpectomy lasted significantly longer (229.6 ± 74.9 min vs. 123.9 ± 47.5 min; p < 0.001). Higher in-hospital and 90-day mortality and readmission rates were observed in the corpectomy group, but the difference was not statistically significant. Both surgeries significantly improved blood infection parameters and neurological status at discharge. Revision surgery due to pseudoarthrosis was required in two patients after corpectomy. CONCLUSIONS We showed that both ACDF and corpectomy for ventrally located CSEA can be considered as safe treatment strategies for patients aged 80 years and above. However, the surgical approach should be carefully weighed and discussed with the patients and their relatives.
Collapse
|
8
|
Mariniello G, Corvino S, Corazzelli G, Maiuri F. Cervical epidural abscess complicated by a pharyngoesophageal perforation after anterior cervical spine surgery for subaxial spondylodiscitis. Surg Neurol Int 2023; 14:102. [PMID: 37025524 PMCID: PMC10070333 DOI: 10.25259/sni_114_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/09/2023] [Indexed: 04/08/2023] Open
Abstract
Background The anterior approach to the cervical spine is safe and effective, but not without risks. The pharyngoesophageal perforation (PEP) is a rare but potentially life-threatening complication of this surgical route. A prompt diagnosis and adequate treatment are crucial for the prognosis; nevertheless, there is no unique consent about the best management. Case Description A 47-year-old woman was referred to our neurosurgical unit for clinical and neuroradiological signs of multilevel cervical spine spondylodiscitis, which was conservatively treated with long-term antibiotic therapy and cervical immobilization after computed tomography-guided biopsy. Nine months later, when the infection was resolved, the patient underwent C3-C6 spinal fusion with anterior plate and screws through anterior approach to the cervical spine for degenerative vertebral changes causing severe myelopathy, and C5- C6 retrolisthesis with instability. Five days after surgical procedure, the patient developed a pharyngoesophageal-cutaneous fistula, detected through wound drainage, and confirmed by swallowing contrast study, without systemic signs of infection. The PEP was conservatively treated, with antibiotic therapy and parenteral nutrition, and it was monitored through seriate swallowing contrast and magnetic resonance studies up to the complete resolution. Conclusion The PEP is a potentially fatal complication of the anterior cervical spine surgery. We suggest an accurate intraoperative control of the pharyngoesophageal's tract integrity at the end of the surgical procedure and a longtime follow-up, because the risk of occurrence is up to several years after surgery.
Collapse
Affiliation(s)
- Giuseppe Mariniello
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University, Naples, Italy
| | - Sergio Corvino
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University, Naples, Italy
| | - Giuseppe Corazzelli
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University, Naples, Italy
- Corresponding author: Giuseppe Corazzelli, Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University, Naples, Italy.
| | - Francesco Maiuri
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University, Naples, Italy
| |
Collapse
|
9
|
Stangenberg M, Mende KC, Mohme M, Krätzig T, Viezens L, Both A, Rohde H, Dreimann M. Influence of microbiological diagnosis on the clinical course of spondylodiscitis. Infection 2021; 49:1017-1027. [PMID: 34254283 PMCID: PMC8476479 DOI: 10.1007/s15010-021-01642-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/15/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE This study sought to recognize differences in clinical disease manifestations of spondylodiscitis depending on the causative bacterial species. METHODS We performed an evaluation of all spondylodiscitis cases in our clinic from 2013-2018. 211 patients were included, in whom a causative bacterial pathogen was identified in 80.6% (170/211). We collected the following data; disease complications, comorbidities, laboratory parameters, abscess occurrence, localization of the infection (cervical, thoracic, lumbar, disseminated), length of hospital stay and 30-day mortality rates depending on the causative bacterial species. Differences between bacterial detection in blood culture and intraoperative samples were also recorded. RESULTS The detection rate of bacterial pathogens through intraoperative sampling was 66.3% and could be increased by the results of the blood cultures to a total of 80.6% (n = 170/211). S. aureus was the most frequently detected pathogen in blood culture and intraoperative specimens and and was isolated in a higher percentage cervically than in other locations of the spine. Bacteremic S. aureus infections were associated with an increased mortality (31.4% vs. overall mortality of 13.7%, p = 0.001), more frequently developing complications, such as shock, pneumonia, and myocardial infarction. Comorbidities, abscesses, length of stay, sex, and laboratory parameters all showed no differences depending on the bacterial species. CONCLUSION Blood culture significantly improved the diagnostic yield, thus underscoring the need for a structured diagnostic approach. MSSA spondylodiscitis was associated with increased mortality and a higher incidence of complications.
Collapse
Affiliation(s)
- Martin Stangenberg
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Klaus Christian Mende
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Theresa Krätzig
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lennart Viezens
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Anna Both
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Dreimann
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| |
Collapse
|
10
|
A case report of cervical spondylodiscitis. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
11
|
Epstein N. Diagnosis, and Treatment of Cervical Epidural Abscess and/or Cervical Vertebral Osteomyelitis with or without Retropharyngeal Abscess; A Review. Surg Neurol Int 2020; 11:160. [PMID: 32637213 PMCID: PMC7332491 DOI: 10.25259/sni_294_2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Every year approximately 19.6 patients/100,000 per year are admitted to hospitals with spinal epidural abscesses (CSEA), 7.4/100,000 have vertebral osteomyelitis (VO)/100,000/year, while 4.1/100.000 children/year have cervical retropharyngeal abscesses (RPA) (i.e., data insufficient for adults). Methods: Here we evaluated 11 individual case studies, 6 multiple patient series, and looked at 9 general review articles focusing on CSEA, and/or VO, with/without RPA. Results: Of the 11 case studies involving 15 patients, 14 had cervical spinal epidural abscesses (CSEA: 10 CSEA/ VO/RPA, 2 CSEA/VO, 1 CSEA/TSEA, 1 CSEA/ TSEA/LSEA), 13 had cervical osteomyelitis (VO: 11 VO/CSEA, 2 VO/RPA), and 12 had cervical retropharyngeal abscesses (RPA: 10 RPA/CSEA/VO, 2 RPA/VO alone). When patients were treated surgically, they required 12 anterior, and 2 posterior approaches; 1 patient required no surgery. In the 6 larger cervical series involving 355 patients, 4 series involved CSEA (3 CSEA, 1 CSEA/VO), and 2 seires had cervical VO. Primary surgery was performed in 298 patients, while 57 were initially managed medically; 24 of these latter patients failed non-surgical therapy, and required delayed cervical surgery. Notably, all 17 clinical studies advocated early surgery where clinically appropriate for varying combinations of CSEA and/or VO with or without RPA. The 8 final articles reviewed all-levels of SEA and or VO, while also providing additional unique information regarding RPA. Conclusion: We analyzed 11 case studies and 6 multiple case series regarding the diagnosis and treatment of combinations of cervical CSEA, and/or VO with or without RPA. We also reviewed 8 articles on the evaluation/ management of all-level SEAs and/or VOs, along with the unique features of RPAs.
Collapse
Affiliation(s)
- Nancy Epstein
- Clinical Professor of Neurosurgery, School of Medicine, State University of New York at Stony Brook
| |
Collapse
|
12
|
Alas H, Fernando H, Baker JF, Brown AE, Bortz C, Naessig S, Pierce KE, Ahmad W, Diebo BG, Passias PG. Comparative outcomes of operative relative to medical management of spondylodiscitis accounting for frailty status at presentation. J Clin Neurosci 2020; 75:134-138. [PMID: 32171646 DOI: 10.1016/j.jocn.2020.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/02/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Investigate outcomes in a spondylodiscitis (SD) patient cohort undergoing operative and medical treatment or medical treatment alone, accounting for frailty status at presentation. METHODS Patients >18 years old undergoing treatment for SD were retrospectively analyzed. The diagnosis of SD was made through a combination of clinical findings, MRI/CT findings, and blood/tissue cultures. Those who failed to respond to antibiotics, had deteriorating markers, or developed neurologic compromise were considered operative candidates. Patients were stratified based on operative (Op, operative plus medical management) or conservative (Cons, medical only) treatment. Univariate analyses identified differences in outcome measures across treatment groups. Conditional forward regression equations, controlling for patient age, identified predictors of increased mortality and inferior outcomes. RESULTS 116 patients with SD were included. 73 underwent Cons treatment and 43 were Op. Op patients were significantly younger (62.9vs70.7yrs; p < 0.001) and less frail (1.09vs1.85; p < 0.006) than Cons patients, with significantly higher WCC and ESR. Cons pts had higher rates of isolated SD, but Op pts had higher rates of SD with associated SEA, VOM, psoas abscess, and para-vertebral abscess (all p < 0.05). Op pts had significantly lower 30-day mortality than Cons pts (2.3%vs17.8%, p = 0.016), and trended lower 1Y mortality (11.6%vs20.5%, p = 0.310) with similar SD recurrence rates (11.6%vs16.4%, p = 0.592). Patients with an mFI > 3 had significantly higher 30-day mortality (30.4% vs 7.5%, p = 0.003) and trended higher 1-year mortality regardless of intervention. CONCLUSIONS Operative intervention was associated with lower 30-day mortality significantly and 1-year mortality compared to conservative treatment, while an increased mFI was associated with higher short-term mortality.
Collapse
Affiliation(s)
- Haddy Alas
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, United States
| | - Hasanga Fernando
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Joseph F Baker
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Avery E Brown
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, United States
| | - Cole Bortz
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, United States
| | - Sara Naessig
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, United States
| | - Katherine E Pierce
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, United States
| | - Waleed Ahmad
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, United States
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, State University of New York Downstate Medical Center, Brooklyn, NY, United States
| | - Peter G Passias
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, United States.
| |
Collapse
|
13
|
Tonetti DA, Eichar B, Ares WJ, Kanter AS, Hamilton DK. Should the Presence of Spondylodiscitis Alter the Surgical Treatment of Patients with Symptomatic Ventral Cervical Epidural Abscesses? An Institutional Analysiss. World Neurosurg 2020; 138:e282-e288. [PMID: 32112938 DOI: 10.1016/j.wneu.2020.02.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spinal epidural abscess is a rare pathology with an incidence that has tripled in the past 2 decades. Ventral cervical epidural abscesses (vCEA) of the cervical spine pose particular treatment challenges because of the anatomical location. The aim of this report is to identify trends in the surgical management of these patients and to determine whether concomitant spondylodiscitis warrants fusion at the index surgery. METHODS Patients presenting to a quaternary care institution from January 2009 to December 2018 with isolated vCEA were identified. Patients were excluded if they had dorsal or circumferential epidural abscesses. Clinical and radiographic data were collected. Patients with vCEA were stratified by the presence or absence of spondylodiscitis upon presentation. Clinical outcomes analyzed included neurological sequelae and the need for revision surgery. RESULTS During the 10-year study period, 36 patients presented with symptomatic isolated vCEA and constituted the study cohort; 16 (44%) had concurrent spondylodiscitis. All 36 patients underwent surgical decompression; the initial surgical approach was anterior-only for 7 patients (19%), posterior-only for 27 patients (75%), and and a combined approach for 2 patients (6%). Four patients from the total cohort (11%) ultimately required a revision operation; all 4 were from the subset with concurrent spondylodiscitis (25% vs. 0%, P = 0.03). CONCLUSIONS vCEA can be evacuated safely and effectively by a variety of strategies in patients with neurologic deficits. Concomitant spondylodiscitis with cervical epidural abscess may warrant instrumented fusion as part of the initial surgical strategy.
Collapse
Affiliation(s)
- Daniel A Tonetti
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Bradley Eichar
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William J Ares
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David Kojo Hamilton
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
14
|
Treatment considerations for cervical and cervicothoracic spondylodiscitis associated with esophageal fistula due to cancer history or accidental injury: a 9-patient case series. Acta Neurochir (Wien) 2019; 161:1877-1886. [PMID: 31256278 DOI: 10.1007/s00701-019-03985-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The combination of cervical spondylodiscitis and esophageal fistula is rare but life-threatening. Due to both the rarity of these conditions' coincidence and the complexity and heterogeneity of individual cases, there is no optimal treatment or management approach. The aims of this study are to obtain an overview of patients' outcomes and to discuss treatment options. METHOD This study is a retrospective analysis of patients who presented with cervical spondylodiscitis and associated esophageal fistula between January 2010 and November 2018. We examined reports of 59 patients who suffered from cervical spondylodiscitis and included nine patients (15.25%) who had an esophageal fistula as the underlying cause. We assessed clinical findings, treatment, and outcome. RESULTS Three of the nine patients were female, and the mean age of the sample was 64.56 years. Six of the patients had a history of esophagopharyngeal cancer and had undergone tumor resection followed by radiotherapy. Two of the remaining patients' fistulas were caused by an iatrogenic injury during cervical spine surgery and a swallowed toothpick; in the final case, the origin remained unclear. Five patients presented with tetraparesis or tetraplegia, and the other four patients were neurologically intact. In seven cases, dorsal instrumentation was initially performed. Three patients secondarily received a ventral approach for debridement, and one received explantation of the ventral implants. Two patients died during the hospital stay, and three were transferred to a palliative care unit. Thus, the spondylodiscitis and esophageal fistula were cured in only four patients. At discharge, two patients were neurologically intact, two others remained in tetraparesis. CONCLUSIONS Cervical spondylodiscitis in association with an esophageal fistula carries high morbidity and high mortality. Because patients whose infections are not cured have high morbidity, we recommend using interdisciplinary and individual management, including definite surgical treatment of the discitis and fistula, in every case.
Collapse
|
15
|
Burkhardt BW, Müller SJ, Wagner AC, Oertel JM. Anterior cervical spine surgery for the treatment of subaxial cervical spondylodiscitis: a report of 30 consecutive patients. Neurosurg Focus 2019; 46:E6. [DOI: 10.3171/2018.10.focus18464] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/22/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEInfection of the cervical spine is a rare disease but is associated with significant risk of neurological deterioration, morbidity, and a poor response to nonsurgical management. The ideal treatment for cervical spondylodiscitis (CSD) remains unclear.METHODSHospital records of patients who underwent acute surgical management for CSD were reviewed. Information about preoperative neurological status, surgical treatment, peri- and postoperative processes, antibiotic treatment, repeated procedure, and neurological status at follow-up examination were analyzed.RESULTSA total of 30 consecutive patients (17 male and 13 female) were included in this retrospective study. The mean age at procedures was 68.1 years (range 50–82 years), with mean of 6 coexisting comorbidities. Preoperatively neck pain was noted in 21 patients (70.0%), arm pain in 12 (40.0%), a paresis in 12 (40.0%), sensory deficit in 8 (26.7%), tetraparesis in 6 (20%), a septicemia in 4 (13.3%). Preoperative MRI scan revealed a CSD in one-level fusion in 21 patients (70.0%), in two-level fusions in 7 patients (23.3%), and in three-level fusions in 2 patients (6.7%). In 16 patients an antibiotic treatment was initiated prior to surgical treatment. Anterior cervical discectomy and fusion with cervical plating (ACDF+CP) was performed in 17 patients and anterior cervical corpectomy and fusion (ACCF) in 12 patients. Additional posterior decompression was performed in one case of ACDF+CP and additional posterior fixation in ten cases of ACCF procedures. Three patients died due to multiple organ failure (10%). Revision surgery was performed in 6 patients (20.7%) within the first 2 weeks postoperatively. All patients received antibiotic treatment for 6 weeks. At the first follow-up (mean 3 month) no recurrent infection was detected on blood workup and MRI scans. At final follow-up (mean 18 month), all patients reported improvement of neck pain, all but one patients were free of radicular pain and had no sensory deficits, and all patients showed improvement of motor strength. One patient with preoperative tetraparesis was able to ambulate.CONCLUSIONSCSD is a disease that is associated with severe neurological deterioration. Anterior cervical surgery with radical debridement and appropriate antibiotic treatment achieves complete healing. Anterior cervical plating with the use of polyetheretherketone cages has no negative effect of the healing process. Posterior fixation is recommended following ACCF procedures.
Collapse
|
16
|
Boody BS, Tarazona DA, Vaccaro AR. Evaluation and Management of Pyogenic and Tubercular Spine Infections. Curr Rev Musculoskelet Med 2018; 11:643-652. [PMID: 30280287 PMCID: PMC6220010 DOI: 10.1007/s12178-018-9523-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To review the most current diagnostic tools and treatment options for pyogenic and tubercular spine infection. RECENT FINDINGS Recent studies have focused on risk factors for failed nonoperative management in order to improve patient selection. Also, spine instrumentation and different grafting options have been safely utilized in the setting of an active infection without increasing the incidence of reoccurrence. However, the optimal surgical technique has yet to be established and instead should be patient specific. Spine infections include a broad spectrum of disorders including discitis, vertebral osteomyelitis, and spinal epidural abscess. It is paramount to recognized spine infections early due to the potential catastrophic consequences of paralysis and sepsis. The management of spine infections continues to evolve as newer diagnostic tools and surgical techniques become available. Magnetic resonance imaging with contrast is the imaging study of choice and computed tomography-guided biopsies are crucial for guiding antibiotic selection. Antibiotics are the mainstay of treatment and surgery is indicated in patients with neurological deficits, sepsis, spinal instability, and those who have failed nonoperative treatment.
Collapse
Affiliation(s)
- Barrett S Boody
- The Rothman Institute, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Daniel A Tarazona
- The Rothman Institute, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- The Rothman Institute, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| |
Collapse
|
17
|
Yang CS, Zhang LJ, Sun ZH, Yang L, Shi FD. Acute prevertebral abscess secondary to intradiscal oxygen-ozone chemonucleolysis for treatment of a cervical disc herniation. J Int Med Res 2018; 46:2461-2465. [PMID: 29584512 PMCID: PMC6023037 DOI: 10.1177/0300060518764186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective We herein present a case involving a prevertebral abscess complicated by a spinal epidural abscess (SEA) secondary to intradiscal oxygen–ozone chemonucleolysis for treatment of a cervical disc herniation. Methods A 67-year-old woman with a history of intradiscal oxygen–ozone chemonucleolysis developed numbness and weakness in her right upper and bilateral lower extremities followed by urinary retention. Her symptoms did not respond to intravenous antibiotics alone. Magnetic resonance imaging of the cervical region revealed an extensive SEA anterior to the spinal cord, spinal cord myelopathy due to anterior compression by the lesion, and a prevertebral abscess extending from C2 to T1. She underwent surgical drainage and irrigation. Results The patient was successfully treated with surgical drainage and systemic antibiotic therapy without kyphosis. Streptococcus intermedius was detected within the abscess. All clinical symptoms except for the sensory deficit in the left leg were relieved. Conclusions The safety of intradiscal oxygen–ozone therapy requires further assessment. High-dose intravenous antibiotics should be initiated empirically at the earliest possible stage of prevertebral and epidural abscesses. Surgical drainage may be a rational treatment choice for patients with a prevertebral abscess complicated by an SEA and spinal cord myelopathy.
Collapse
Affiliation(s)
- Chun-Sheng Yang
- 1 Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Lin-Jie Zhang
- 1 Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhi-Hua Sun
- 2 Department of Radiology, Tianjin Medical University General Hospital Tianjin, China
| | - Li Yang
- 1 Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Fu-Dong Shi
- 1 Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China.,3 Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| |
Collapse
|