Vertebral osteomyelitis in adults: an update

Vertebral osteomyelitis: a comparative, single-center study in northwestern China

BACKGROUND

Vertebral osteomyelitis (VO) is an infection of the spine with increasing prevalence due to improved diagnostics and aging populations. Multiple pathogens, including Mycobacterium tuberculosis, Brucella spp., and pyogenic bacteria, can cause VO, making differential diagnosis complex, especially in regions with endemic brucellosis and tuberculosis. Early and accurate diagnosis is essential for appropriate treatment.

METHODS

This was a single-center, retrospective, observational study performed between 2019 and 2022 in Kashi, Xinjiang.

RESULTS

In this study, a total of 319 patients were enrolled, comprising 45.5% with tuberculous vertebral osteomyelitis (TVO; 52.4% females), 37.9% with brucellar vertebral osteomyelitis (BVO; 19.8% females), and 16.6% with pyogenic vertebral osteomyelitis (PVO; 52.8% females). Demographically, TVO had a longer mean time to diagnosis compared to BVO and PVO. BVO was more prevalent in male, and PVO patients had higher rates of spinal surgery history (45.3%) and diabetes (13.2%). Clinically, TVO patients presented with fever (72.4%), sweating (83.4%), weight loss (71.7%), and appetite loss (84.8%) more frequently, while BVO patients reported more lower back pain (86.0%). Laboratory investigations revealed significantly higher leucocyte and neutrophil levels in PVO, whereas TVO patients had elevated monocyte-to-lymphocyte and platelet-to-lymphocyte ratios. Radiologically, TVO patients exhibited a higher incidence of thoracic involvement (56.6%) and skip lesions (20%). Microbiologically, BVO and PVO had high positive culture rates (84.3 and 84.9%, respectively), with M. tuberculosis isolated from only 4.1% of TVO patients.

CONCLUSION

These findings underscore the distinct clinical, laboratory, and radiological characteristics of TVO, BVO, and PVO.

Evaluation of the Efficacy of Unilateral Biportal Endoscopic Lamina Osteotomy Replantation Assisted by Ultrasonic Bone Scalpel in the Treatment of Lumbar Infectious Spondylitis

OBJECTIVE

To analyze the clinical efficacy of ultrasonic bone scalpel (UBS)-assisted unilateral biportal endoscopic lamina osteotomy replantation (ULOR) for treating lumbar infectious spondylitis (LIS).

METHODS

We conducted a retrospective analysis of patients with LIS who had therapy with UBS-assisted ULOR at our hospital between January 2020 and May 2023. A total of 17 instances matched the inclusion criteria, consisting of 7 females and 10 males. The UBS was utilized during surgery to extract the lamina completely, followed by large bone grafting to fuse the cleaned intervertebral space. The study recorded and analyzed various parameters in the included patients before and after surgery.

RESULTS

All 17 patients underwent a successful operation with an average duration of 136.82 ± 21.35 minutes, average blood loss of 77.43 ± 10.19 ml, and an average follow-up period of 18.55 ± 3.47 months. Following the surgical intervention, the patients experienced a substantial improvement in their clinical symptoms, accompanied by a significant drop in white blood cell, erythrocyte sedimentation rate, and C-reactive protein levels (all P < 0.001). The postoperative visual analog scale scores and Oswestry Disability Index showed considerable improvement (both P < 0.001). The postoperative Cobb angle and intervertebral space height were significantly corrected (P < 0.001). At the last follow-up, the success rate of lumbar fusion was 100%, and there were no instances of infection recurring.

CONCLUSIONS

The use of ULOR with assistance from UBS for the treatment of LIS has proven to be beneficial. It provides significant relief from symptoms and corrects lumbar deformity. This surgical procedure is both effective and safe.

Factors prolonging antibiotic duration and impact of early surgery in thoracolumbar pyogenic spondylitis treated with minimally invasive posterior fixation

PURPOSE

A standard 6-12-week course of antibiotics is recommended for pyogenic spondylitis. Recent evidence supports early minimally invasive posterior fixation surgery; however, its effect on antibiotic treatment duration is unclear. This study aims to identify factors associated with prolonged antibiotic treatment in thoracolumbar pyogenic spondylitis patients resistant to conservative treatment and assess whether early surgery can reduce treatment duration.

METHODS

We retrospectively reviewed 74 patients with thoracolumbar pyogenic spondylitis undergoing minimally invasive posterior fixation at nine facilities. Patients were grouped based on antibiotic duration (≥ 6 or < 6 weeks) and timing of surgery (≤ 3 weeks or > 3 weeks of starting antibiotics). Univariable and multivariable logistic regression analyses were used to identify factors associated with prolonged antibiotic treatment and study the outcomes of patients undergoing early surgery.

RESULTS

Forty-nine patients (66%) required prolonged antibiotic treatment. The presence of an iliopsoas abscess (p = 0.0006) and elevated C-reactive protein (CRP) levels (≥ 10 mg/dL, p = 0.015) were independently associated with prolonged antibiotic treatment. Early surgery significantly reduced total antibiotic duration (5.3 weeks vs. 9.9 weeks, p < 0.0001) without increasing the incidence of postoperative infection recurrences and unplanned additional surgeries. Despite factors associated with prolonged antibiotic treatment, early surgery consistently shortened the treatment duration compared to late surgery.

CONCLUSIONS

Early surgery (within three weeks) with minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis is associated with reduced antibiotic duration and overall treatment duration regardless of the presence of prolonging factors like iliopsoas abscess and elevated CRP levels.

Comparison of Disc Degeneration between Pyogenic Spondylitis and Noninfected Lumbar Spondylosis: A Multicenter Retrospective Study with Propensity Score Matching

Introduction

Disc degeneration is a risk factor of pyogenic spondylitis. However, its degree in patients with pyogenic spondylitis is unknown. This study aimed to determine differences in disc degeneration between patients with pyogenic spondylitis and those with noninfectious lumbar spondylosis.

Methods

A total of 85 patients with lumbar pyogenic spondylitis (the infected group) and 156 with lumbar spondylosis who underwent posterior lumbar interbody fusion (the noninfected group) were retrospectively evaluated. Patients with a previous history of spinal fusion, tuberculous spondylitis, and multilevel infection and those receiving dialysis were excluded. Magnetic resonance imaging of the lumbar spine was conducted. Each disc at the L1/2-L5/S levels was graded. The total score of the four discs, excluding the affected disc, was used as the modified disc degenerative disease (DDD) score. Propensity score matching was performed using independent variables such as age, sex, diabetes mellitus, cancer, and steroid use. The modified DDD scores at all and each disc level were compared between the two matched groups.

Results

After matching, 48 patients in the infected group and 88 in the noninfected group were finally included in the study. The mean modified DDD scores of the infected and noninfected groups were 7.63 and 5.40, respectively. The modified DDD scores at all and each disc level were higher in the infected group than in the noninfected group.

Conclusions

The incidence of disc degeneration at all and each disc level was higher in patients with pyogenic spondylitis than in those with noninfectious lumbar spondylosis.

Current knowledge of vertebral osteomyelitis: a review

PURPOSE

As life expectancy increases worldwide, the elderly population in every country is growing in both the size and proportion. This review aims to provide a comprehensive overview of the microbiology, clinical presentation, diagnostic strategies, and therapeutic approaches to vertebral osteomyelitis, summarizing the latest evidence to guide effective treatment.

METHODS

A comprehensive literature search was conducted using the Medline and Embase databases to identify relevant studies on vertebral osteomyelitis. The search included the following keywords: "vertebral osteomyelitis," "spinal infection," "discitis," "spondylitis," " spondylodiscitis," and "spinal epidural abscess." Both retrospective and prospective studies, case series, and reviews were considered.

RESULTS

This condition is commonly caused by bacteria such as Staphylococcus aureus or gram-negative bacilli, but can also be caused by other pathogens like fungi and parasites. The onset of vertebral osteomyelitis is insidious, with low specificity in clinical manifestations, often making early diagnosis difficult. Delayed or inadequate treatment may lead to sepsis, permanent neurological damage, or even death. Treatment strategies emphasize the importance of identifying the causative pathogen to guide effective antimicrobial therapy. Current consensus does not advocate for empirical antibiotic treatment unless patients exhibit signs of neurological impairment or severe sepsis. Severe cases involving neurological paralysis, spinal instability, or sepsis may require surgical intervention.

CONCLUSION

Vertebral osteomyelitis requires prompt diagnosis and treatment for a good prognosis. Delayed diagnosis and treatment can lead to permanent neurological deficits or death. Identifying the causative organism is crucial for guiding appropriate antimicrobial therapy. In addition to conservative and surgical treatments, local drug delivery systems offer new approaches to managing spinal osteomyelitis.

Predictors of conversion surgery after conservative treatment for pyogenic spondylitis

BACKGROUND

Patient demographic and clinical characteristics may be factors associated with the success of conservative treatment for pyogenic spondylitis. The ability of imaging findings at initial diagnosis to predict patient outcomes remains unclear. The aim of this study was to investigate the risk factors associated with conversion surgery after conservative treatment for pyogenic spondylitis, with a special focus on the initial computed tomography (CT) findings.

METHODS

This study enrolled 35 patients with pyogenic spondylitis who underwent CT and magnetic resonance imaging (MRI) at diagnosis and were followed-up for more than 6 months. Patients were diagnosed by MRI, and the degree of bone destruction was assessed on CT cross-sectional images. Vertebral body destruction was classified as grades 0 (almost normal), 1 (endplate irregularity), 2 (vertebral body destruction not involving the posterior wall), and 3 (destruction involving the posterior wall). Patients were divided into four groups based on grade of bone destruction and their clinical characteristics were compared.

RESULTS

1, 11, 11, and 12 patients were classified as grades 0, 1, 2, and 3, respectively. Univariate analysis showed no significant differences in the demographic and clinical characteristics of the four groups. Eighteen (51.4 %) patients had been treated surgically, with the rate of surgical treatment being significantly higher in patients with grade 3 (83.3 %) than in those with grades 0 + 1 (25 %) and grade 2 (45.5 %) (P < 0.05). Multivariate analysis showed that epidural abscess on MRI (odds ratio [OR] 10.8, 95 % confidence interval [CI] 1.68-69.7), grade 3 bone destruction on CT (OR 3.97, 95 % CI 1.21-13.0), and C-reactive protein (CRP) improvement rate after 1 week of treatment (OR 0.95, 95 % CI 0.91-0.99) were risk factors for surgery.

CONCLUSIONS

Early surgical treatment should be considered for patients with pyogenic spondylitis who present with an epidural abscess on MRI and bone destruction extending to the posterior wall on CT at the time of diagnosis.

Quality of Life with Respect to Surgically Treated Vertebral Osteomyelitis and Degenerative Spondylolisthesis

Vertebral osteomyelitis (VO) and degenerative spondylolisthesis (SL) are 2 commonly treated spinal conditions. Therefore, in the presented work, the quality of life after surgical therapy of these 2 entities is compared using established scores.In a monocentric study, all patients with VO and SL were prospectively enrolled using the Spine Tango Registry. Surgical procedures included one- or two-stage fusion of the affected segments. Quality of life was assessed using the Core Outcome Measures Index (COMI) and the Oswestry Disability Index (ODI) at time points t0 (0 months), t1 (12 months), and t2 (24 months). Statistical analysis was performed using SPSS. The level of significance was set at 5%.52 patients with VO and 48 patients with SL were included in the analysis. There were no significant differences in age and gender distribution. The length of stay in the SL group was significantly shorter (p < 0.001). ODI at time t0 was significantly higher in the VO group (p < 0.001), whereas COMI scores did not differ significantly (p = 0.155). At time points t1 and t2, the differences between the VO and SL groups were not significantly different for either the ODI score (p = 0.176; p = 0.250) or the COMI score (p = 0.682; p = 0.640).Postoperative quality of life scores after lumbar fusion surgery in SL and VO are comparable despite different indications and medical conditions. In both groups, similar quality of life with in patient with chronic back pain was achieved. This should be considered for the preoperative assessment, as well as for the indication for surgery in SL.

Imaging review of the atypical spinal epidural space pathologies

Pathologies affecting the spinal epidural space (SES) comprise various abnormalities. However, they all have the potential to cause thecal sac narrowing or spinal cord compression. In this review, we group these pathologies into degenerative, infective, neoplastic, vascular, traumatic, and others, focusing on their imaging features. Degenerative pathologies of the SES range from disc to facet disease, with a particular emphasis on the less common degenerative pathologies in this review. Infective pathologies affecting the epidural space include spondylodiscitis and associated epidural phlegmon and abscess. Neoplasms arising from typical SES components include neurofibroma, hemangioma, and liposarcoma. MRI is the best modality to assess the anatomy and abnormalities of the epidural space. MRI, combined with computed tomography, or a radiograph, is useful for the evaluation of bones or radiopaque foreign bodies.

Imaging protocols for non-traumatic spinal cord injury: current state of the art and future directions

INTRODUCTION

Non-traumatic spinal cord injury (NTSCI) is a term used to describe damage to the spinal cord from sources other than trauma. Neuroimaging techniques such as computerized tomography (CT) and magnetic resonance imaging (MRI) have improved our ability to diagnose and manage NTSCIs. Several practice guidelines utilize MRI in the diagnostic evaluation of traumatic and non-traumatic SCI to direct surgical intervention.

AREAS COVERED

The authors review practices surrounding the imaging of various causes of NTSCI as well as recent advances and future directions for the use of novel imaging modalities in this realm. The authors also present discussions around the use of simple radiographs and advanced MRI modalities in clinical settings, and briefly highlight areas of active research that seek to advance our understanding and improve patient care.

EXPERT OPINION

Although several obstacles must be overcome, it appears highly likely that novel quantitative imaging features and advancements in artificial intelligence (AI) as well as machine learning (ML) will revolutionize degenerative cervical myelopathy (DCM) care by providing earlier diagnosis, accurate localization, monitoring for deterioration and neurological recovery, outcome prediction, and standardized practice. Some intriguing findings in these areas have been published, including the identification of possible serum and cerebrospinal fluid biomarkers, which are currently in the early phases of translation.

Pedicle screw insertion into infected vertebrae reduces operative time and range of fixation in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis: a multicenter retrospective cohort study

BACKGROUND

Minimally invasive posterior fixation surgery for pyogenic spondylitis is known to reduce invasiveness and complication rates; however, the outcomes of concomitant insertion of pedicle screws (PS) into the infected vertebrae via the posterior approach are undetermined. This study aimed to assess the safety and efficacy of PS insertion into infected vertebrae in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis.

METHODS

This multicenter retrospective cohort study included 70 patients undergoing minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis across nine institutions. Patients were categorized into insertion and skip groups based on PS insertion into infected vertebrae, and surgical data and postoperative outcomes, particularly unplanned reoperations due to complications, were compared.

RESULTS

The mean age of the 70 patients was 72.8 years. The insertion group (n = 36) had shorter operative times (146 versus 195 min, p = 0.032) and a reduced range of fixation (5.4 versus 6.9 vertebrae, p = 0.0009) compared to the skip group (n = 34). Unplanned reoperations occurred in 24% (n = 17) due to surgical site infections (SSI) or implant failure; the incidence was comparable between the groups. Poor infection control necessitating additional anterior surgery was reported in four patients in the skip group.

CONCLUSIONS

PS insertion into infected vertebrae during minimally invasive posterior fixation reduces the operative time and range of fixation without increasing the occurrence of unplanned reoperations due to SSI or implant failure. Judicious PS insertion in patients with minimal bone destruction in thoracolumbar pyogenic spondylitis can minimize surgical invasiveness.

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.

Technical Nuances of Anterior Column Construction for the Treatment of Osteomyelitis-Induced Cervical Kyphoscoliotic Deformity: An Operative Video Illustration

Pyogenic vertebral osteomyelitis is a bacterial infection of the vertebral body often caused by hematogenous spread from a distant site with 3%-11% of cases affecting the cervical spine.1,2 Patients at risk for osteomyelitis are intravenous drug users, patients with diabetes, patients in dialysis, and males older than 50 years of age. In severe cases where infection causes osseous destruction of the vertebral column lending to a loss of normal sagittal and coronal plane alignment, neurologic impairment, or spinal instability, surgical correction may be required.3 A 38-year-old woman with a medical history of intravenous drug use presented with a 1-week history of progressive paresthesias, subjective loss of lower extremity sensation, and severe right upper extremity weakness. Neurologic examination was notable for significant weakness in the right deltoids, biceps, and triceps. Magnetic resonance imaging cervical spine revealed significant kyphosis at C4-C5 secondary to destruction of the C4 and C5 vertebral bodies and anterior and posterior epidural fluid collection at C2-C3 and C7-T1, respectively. Surgery was proposed through a combined anteroposterior approach with head and neck surgeons. Anteriorly, she underwent a C2-C3 and C6-C7 ACDF and C4, C5 corpectomies (Video 1). The patient was then transitioned to the prone position and underwent C3-T3 posterior fusion with instrumentation and C3-C7 laminectomies. Correction of sagittal imbalance should restore normal physiologic spinal alignment while promoting a successful fusion.4 The patient was discharged to acute rehabilitation after an uneventful postoperative course. At 5-month follow-up, she has regained antigravity strength in right upper extremity and reports significant reduction in neck pain.

Biofilm Producing Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in Humans: Clinical Implications and Management

Since its initial description in the 1960s, methicillin-resistant Staphylococcus aureus (MRSA) has developed multiple mechanisms for antimicrobial resistance and evading the immune system, including biofilm production. MRSA is now a widespread pathogen, causing a spectrum of infections ranging from superficial skin issues to severe conditions like osteoarticular infections and endocarditis, leading to high morbidity and mortality. Biofilm production is a key aspect of MRSA's ability to invade, spread, and resist antimicrobial treatments. Environmental factors, such as suboptimal antibiotics, pH, temperature, and tissue oxygen levels, enhance biofilm formation. Biofilms are intricate bacterial structures with dense organisms embedded in polysaccharides, promoting their resilience. The process involves stages of attachment, expansion, maturation, and eventually disassembly or dispersion. MRSA's biofilm formation has a complex molecular foundation, involving genes like icaADBC, fnbA, fnbB, clfA, clfB, atl, agr, sarA, sarZ, sigB, sarX, psm, icaR, and srtA. Recognizing pivotal genes for biofilm formation has led to potential therapeutic strategies targeting elemental and enzymatic properties to combat MRSA biofilms. This review provides a practical approach for healthcare practitioners, addressing biofilm pathogenesis, disease spectrum, and management guidelines, including advances in treatment. Effective management involves appropriate antimicrobial therapy, surgical interventions, foreign body removal, and robust infection control practices to curtail spread within healthcare environments.

Utilization of Antibiotic Bone Cement in Spine Surgery: Pearls, Techniques, and Case Review

Vertebral osteomyelitis (VO) encompasses a spectrum of spinal infections ranging from isolated mild vertebral osteomyelitis to severe diffuse infection with associated epidural abscess and fracture. Although patients can often be treated with an initial course of intravenous antibiotics, surgery is sometimes required in patients with sepsis, spinal instability, neurological compromise, or failed medical treatment. Antibiotic bone cement (ABC) has been widely used in orthopedic extremity surgery for more than 150 years, both for prophylaxis and treatment of bacterial infection. However, relatively little literature exists regarding its utilization in spine surgery. This article describes ABC utilization in orthopedic surgery and explains the technique of ABC utilization in spine surgery. Surgeons can choose from multiple premixed ABCs with variable viscosities, setting times, and antibiotics or can mix in antibiotics to bone cements themselves. ABC can be used to fill large defects in the vertebral body or disc space or in some cases to coat instrumentation. Surgeons should be wary of complications such as ABC extravasation as well as an increased difficulty with revision. With a thorough understanding of the properties of the cement and the methods of delivery, ABC is a powerful adjunct in the treatment of spinal infections.

Determining the prevalence and risk factors for positive bacterial culture in canine discospondylitis: 120 cases

BACKGROUND

Identification of the aetiologic agent in canine discospondylitis is infrequent; and risk factors for a positive bacterial culture have not previously been reported.

METHODS

Medical records at three institutions were searched to identify clinical features of dogs with discospondylitis diagnosed via radiography or cross-sectional imaging. Inclusion in this retrospective case-control study required culture of one or more samples. Multivariable binary logistic regression identified features associated with a positive culture.

RESULTS

Fifty (42%) of 120 dogs had one or more positive culture results obtained from either urine (28/115), blood (25/78), intervertebral disc aspiration (10/34) or cerebrospinal fluid (1/18). A positive culture was associated with higher bodyweight (p = 0.002, odds ratio [OR] = 1.054, 95% confidence interval [CI]: 1.019-1.089), more sample types cultured (p = 0.037, OR = 1.806, 95% CI: 1.037-3.147) and institution (p = 0.021). The presence of possibly associated preceding events (e.g., surgery), pyrexia, number of disc sites affected and serum C-reactive protein result, among other features, were not statistically significant.

LIMITATIONS

All isolates cultured were included since differentiation of true aetiologic agents from contaminants was not possible without histological confirmation and culture from surgical or postmortem biopsies.

CONCLUSIONS

Clinical features typically associated with infection were not identified as risk factors for positive culture in canine discospondylitis. The statistical significance of the institution suggests that standardisation of sampling protocols is necessary.

Vacuum assisted closure and local drug delivery systems in spinal infections: A review of current evidence

Background

Spinal infections are still showing increased incidence throughout the years as our surgical capabilities increase, coupled with an overall aging population with greater number of chronic comorbidities. The management of spinal infection is of utmost importance, due to high rates of morbidity and mortality, on top of the general difficulty in eradicating spinal infection due to the ease of hematogenous spread in the spine. We aim to summarize the utility of vacuum-assisted closure (VAC) and local drug delivery systems (LDDS) in the management of spinal infections.

Methods

A narrative review was conducted. All studies that were related to the use of VAC and LDDS in Spinal Infections were included in the study.

Results

A total of 62 studies were included in this review. We discussed the utility of VAC as a tool for the management of wounds requiring secondary closure, as well as how it is increasingly being used after primary closure as prophylaxis for surgical site infections in high-risk wounds of patients undergoing spinal surgery. The role of LDDS in spinal infections was also discussed, with preliminary studies showing good outcomes when patients were treated with various novel LDDS.

Conclusions

We have summarized and given our recommendations for the use of VAC and LDDS for spinal infections. A treatment algorithm has also been established, to act as a guide for spine surgeons to follow when tackling various spinal infections in day-to-day clinical practice.

Laboratory diagnostics for primary spinal infections in pediatric and adult populations: a narrative review

Primary spinal infection (PSI) is a generic term covering a heterogeneous group of infections that can affect the vertebral body, intervertebral disks, the content of the medullary cavity, and adjacent paraspinal tissues. Patients' characteristics can vary significantly, notably according to their age, and some of these characteristics undoubtedly play a primordial role in the occurrence of a PSI and in the type of offending pathogen. Before approaching the subject of laboratory diagnostics, it is essential to define the characteristics of the patient and their infection, which can then guide the physician toward specific diagnostic approaches. This review critically examined the roles and usefulness of traditional and modern laboratory diagnostics in supporting clinicians' decision-making in cases of pediatric and adult primary spinal infection (PSI). It appears impossible to compare PSIs in children and adults, whether from an epidemiological, clinical, bacteriological, or biological perspective. The recipients are really too different, and the responsible germs are closely correlated to their age. Secondly, the interpretation of traditional laboratory blood tests appears to contribute little guidance for clinicians attempting to diagnose a PSI. Biopsy or needle aspiration for bacterial identification remains a controversial subject, as the success rates of these procedures for identifying causative organisms are relatively uncertain in pediatric populations.Using nucleic acid amplification assays (NAAAs) on biopsy samples has been demonstrated to be more sensitive than conventional cultures for diagnosing PSI. Recent advances in next-generation sequencing (NGS) are particularly interesting for establishing a microbiological diagnosis of a PSI when standard cultures and NAAAs have failed to detect the culprit. We can even imagine that plasma metagenomic NGS using plasma (known as "liquid biopsy") is a diagnostic approach that can detect not only pathogens circulating in the bloodstream but also those causing focal infections, and thus eliminate the need for source sample collection using costly invasive surgical procedures.

The advancement of MRI in differentiating Modic type I degenerative changes from early spinal infections

MRI is the most sensitive and specific imaging method for the detection of advanced spinal infections. However, the differential diagnosis of early spinal infection and Modic Type I degenerative changes based on conventional MRI is difficult clinically, as they both may mimic each other by showing hypointensity on T1 weighted images and hyperintensity on T2 weighted spine MRI images. This review summarizes recent advancements in MRI, which may be useful in discriminating degenerative Modic Type I endplate changes from early spinal infection, and evaluates the diagnostic accuracy and limitations of MRI. We aim to provide indications for early differential diagnosis to help initiate appropriate treatment in a timely manner so that associated complications can be avoided.

Pyogenic Spondylodiscitis Following Nonspinal Cesarean Section

Pyogenic spondylodiscitis is an uncommon bacterial infection of the intervertebral disc and the vertebral endplates. It usually affects elderly patients with comorbidities but may be also seen after surgical procedures in young patients, mostly after spinal interventions and genitourinary procedures. This article describes a rare case of pyogenic spondylodiscitis in a young female patient after a cesarean section without spinal anesthesia. The patient presented with a three-month history of lower back pain, and the inflammatory markers were elevated. The magnetic resonance imaging showed the involvement of the L5-S1 disc space and the adjacent vertebral bodies. The diagnosis was confirmed with needle aspiration of purulent material. The patient was treated with antibiotics for a total of six weeks. After a follow-up of about one year, the patient showed slight degenerative vertebral changes with no signs of residual infection. This case highlights the importance of the early recognition of pyogenic spondylodiscitis as one cause of postoperative back pain after urogenital procedures, even without spinal anesthesia. Only a few similar cases were reported in the literature.

Carbapenem-Resistant Pseudomonas aeruginosa Spondylodiscitis Treated with Ceftazidime-Avibactam: A Case Report with Literature Review

Pyogenic spondylodiscitis (PS) is a highly morbid and potentially fatal bacterial infection with an increasing incidence in recent decades. Its diagnosis and treatment are challenging, especially with the expansion of multidrug- or extensively drug-resistant bacteria. We report a rare case of PS caused by carbapenem-resistant Pseudomonas aeruginosa (CRPA) that was treated with ceftazidime-avibactam (C/A). The choice of C/A therapy was based on the patient's bacterial sensitivity profile and intolerance to the initial therapeutic regimen (polymyxin B and meropenem). The total antimicrobial treatment time was seven weeks. The evolution of the clinical course met the cure criteria, which was characterized by remission of signs and symptoms, normalization of inflammatory markers, and radiological improvement over 18 months of clinical follow-up. This is a rare case of CRPA spondylodiscitis that responded to C/A treatment.

[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.

Usefulness of Percutaneous Drainage in Determining the Causative Microorganism in Patients with Spondylodiscitis: A Retrospective Cross-Sectional Study

Purpose

To determine the usefulness of CT-guided percutaneous drainage for the causative microorganism detection in patients with spondylodiscitis.

Materials and Methods

Data of patients who underwent CT-guided percutaneous drainage for spondylodiscitis from January 2014 to April 2022 were extracted from the radiological database of our hospital and investigated. The administration rate of antibiotics prior to blood culture and CT-guided percutaneous drainage (CTPD) were analyzed. The detection rate of microorganisms via blood culture and CT-guided percutaneous drainage were compared using the Mann-Whitney's U test with the SPSS software.

Results

In this study, a total of 30 (20 male and 10 female) patients were analyzed. A total of 13 patients (43%) were administered antibiotics prior to blood culture. Of them, microorganisms were detected via blood culture in only one patient (7%). A total of 25 patients (83%) were administered antibiotics prior to CTPD. Of them, the causative microorganisms in 19 patients (76%) were detected. Overall, the causative microorganism could be detected in 24 out of 26 patients (92%) via CT-guided percutaneous drainage. There was a statistical significance in the detection rate of microorganisms between blood culture and CTPD (P = 0.004) in favor of CTPD.

Conclusion

CT-guided percutaneous drainage showed a high positive rate of microorganism detection in patients with spondylodiscitis regardless of antibiotic administration prior to the procedure. CT-guided percutaneous drainage can be a solution for the detection of the causative microorganism in spondylodiscitis patients who received antibiotics before obtaining any culture.

Diagnostic Sensitivity of Blood Culture, Intraoperative Specimen, and Computed Tomography-Guided Biopsy in Patients with Spondylodiscitis and Isolated Spinal Epidural Empyema Requiring Surgical Treatment

BACKGROUND

the successful treatment of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) depends on early detection of causative pathogens, which is commonly performed either via blood cultures, intraoperative specimens, and/or image-guided biopsies. We evaluated the diagnostic sensitivity of these three procedures and assessed how it is influenced by antibiotics.

METHODS

we retrospectively analyzed data from patients with SD and ISEE treated surgically at a neurosurgery university center in Germany between 2002 and 2021.

RESULTS

we included 208 patients (68 [23-90] years, 34.6% females, 68% SD). Pathogens were identified in 192 cases (92.3%), including 187 (97.4%) pyogenic and five (2.6%) non-pyogenic infections, with Gram-positive bacteria accounting for 86.6% (162 cases) and Gram-negative for 13.4% (25 cases) of the pyogenic infections. The diagnostic sensitivity was highest for intraoperative specimens at 77.9% (162/208, p = 0.012) and lowest for blood cultures at 57.2% (119/208) and computed tomography (CT)-guided biopsies at 55.7% (39/70). Blood cultures displayed the highest sensitivity in SD patients (SD: 91/142, 64.1% vs. ISEE: 28/66, 42.4%, p = 0.004), while intraoperative specimens were the most sensitive procedure in ISEE (SD: 102/142, 71.8% vs. ISEE: 59/66, 89.4%, p = 0.007). The diagnostic sensitivity was lower in SD patients with ongoing empiric antibiotic therapy (EAT) than in patients treated postoperatively with targeted antibiotic therapy (TAT) (EAT: 77/89, 86.5% vs. TAT: 53/53, 100%, p = 0.004), whereas no effect was observed in patients with ISEE (EAT: 47/51, 92.2% vs. TAT: 15/15, 100%, p = 0.567).

CONCLUSIONS

in our cohort, intraoperative specimens displayed the highest diagnostic sensitivity especially for ISEE, whereas blood cultures appear to be the most sensitive for SD. The sensitivity of these tests seems modifiable by preoperative EAT in patients with SD, but not in those with ISEE, underscoring the distinct differences between both pathologies.

Clinical phenotyping of spondylodiscitis and isolated spinal epidural empyema: a 20-year experience and cohort study

Background

The incidence of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been increasing in the last decades, but the distinct differences between both entities are poorly understood. We aimed to evaluate the clinical phenotypes and long-term outcomes of SD and ISEE in depth.

Methods

We performed a chart review and analyzed data from our cohorts of consecutive SD and ISEE patients who were treated and assessed in detail for demographic, clinical, imaging, laboratory, and microbiologic characteristics at a university neurosurgical center in Germany from 2002 to 2021. Between-group comparisons were performed to identify meaningful differences in both entities.

Results

We included 208 patients (72 females: age 75 [75 32-90] y vs. 136 males: 65 [23-87] y, median [interquartile range], p < 0.001), of which 142 (68.3%) had SD and 66 (31.7%) had ISEE. Patients with SD were older than ISEE (ISEE: 62 y vs. SD: 70 y, p = 0.001). While SD was more common in males than females (males: n = 101, 71.1% vs. females: n = 41, 28.9%, p < 0.001), there was no sex-related difference in ISEE (males: n = 35, 53.0% vs. females: n = 31, 47.0%, p = 0.71). Obesity was more frequent in ISEE than in SD (ISEE: n = 29, 43.9% vs. SD: n = 37, 26.1%, p = 0.016). However, there were no between-group differences in rates of diabetes and immunodeficiency. In the entire study population, a causative pathogen was identified in 192 (92.3%) patients, with methicillin-susceptible staphylococcus aureus being most frequent (n = 100, 52.1%) and being more frequent in ISEE than SD (ISEE: n = 43, 65.2% vs. SD: n = 57, 40.1%, p = 0.003). SD and ISEE occurred most frequently in the lumbar spine, with no between-group differences (ISEE: n = 25, 37.9% vs. SD: n = 65, 45.8%, p = 0.297). Primary infectious sources were identified in 145 patients (69.7%) and among this skin infection was most common in both entities (ISEE: n = 14, 31.8% vs. SD: n = 25, 24.8%, p = 0.418). Furthermore, epidural administration was more frequent the primary cause of infection in ISEE than SD (ISEE: n = 12, 27.3% vs. SD: n = 5, 4.9%, p < 0.001). The most common surgical procedure in SD was instrumentation (n = 87, 61%) and in ISEE abscess evacuation (n = 63, 95%). Patients with ISEE displayed lower in-hospital complication rates compared to SD for sepsis (ISEE: n = 12, 18.2% vs. SD: n = 94, 66.2%, p < 0.001), septic embolism (ISEE: n = 4/48 cases, 8.3% vs. SD: n = 52/117 cases, 44.4%, p < 0.001), endocarditis (ISEE: n = 1/52 cases, 1.9% vs. SD: n = 23/125 cases, 18.4%, p = 0.003), relapse rate (ISEE: n = 4/46, 8.7% vs. SD: n = 27/92, 29.3%, p = 0.004), and disease-related mortality (ISEE: n = 1, 1.5% vs. SD: n = 11, 7.7%, p = 0.108). Patients with SD showed prolonged length of hospital stay (ISEE: 22 [15, 30] d vs. SD: 38 [29, 53] d, p < 0.001) and extended intensive care unit stay (ISEE: 0 [0, 4] d vs. SD: 3 [0, 12] d, p < 0.002).

Conclusions

Our 20-year experience and cohort analysis on the clinical management of SD and ISEE unveiled distinct clinical phenotypes and outcomes in both entities, with ISEE displaying a more favorable disease course with respect to complications and relapse rates as well as disease-related mortality.

Non-typeable Haemophilus influenzae Osteomyelitis and Discitis of the Cervical Vertebrae in an Elderly Adult: A Case Report and Literature Review

While Haemophilus influenzae type B (Hib) is well described in the literature to cause osteomyelitis, non-typeable H. influenzae has not. In areas where vaccination is routine, the prevalence of Hib has declined, whereas, in contrast, the prevalence of non-typeable H. influenza has increased. Generally, the non-typeable strains are less invasive but can access the vascular system by transmural migration through epithelial tight junctions or by an independent intercellular mechanism. Herein, we described a case of a 79-year-old man with the first case of non-typeable H. influenzae causing cervical osteomyelitis with associated bacteremia in an elderly adult.

Site matters: Image-guided percutaneous sampling of intervertebral disc results in increased positive diagnostic yield in spondylodiscitis

Spondylodiscitis is a common referral to spinal on call services. Identification of the causative organism is vital in order to dictate the appropriate antibiotic treatment. In this context, the surgical and interventional radiology team is often asked to perform a diagnostic biopsy. The aim of the present study was to assess whether the sampling location affects the diagnostic yield. Our results suggest that the overall positive diagnostic yield was 35%. When disc material was included in the sample the diagnostic yield significantly improved to 47%. Bone sampling alone had a positive yield of 15%. Age, pre-biopsy CRP, pre-biopsy use of antibiotics did not seem to affect the likelihood of obtaining a positive yield. These results suggests that when performing image guided biopsies for suspected cases of spondylodiscitis the inclusion of disc material is important.

Differentiating Lumbar Spinal Etiology from Peripheral Plexopathies

Clinicians have managed and treated lower back pain since the earliest days of practice. Historically, lower back pain and its accompanying symptoms of radiating leg pain and muscle weakness have been recognized to be due to any of the various lumbar spine pathologies that lead to the compression of the lumbar nerves at the root, the most common of which is the radiculopathy known as sciatica. More recently, however, with the increased rise in chronic diseases, the importance of differentially diagnosing a similarly presenting pathology, known as lumbosacral plexopathy, cannot be understated. Given the similar clinical presentation of lumbar spine pathologies and lumbosacral plexopathies, it can be difficult to differentiate these two diagnoses in the clinical setting. Resultingly, the inappropriate diagnosis of either pathology can result in ineffective clinical management. Thus, this review aims to aid in the clinical differentiation between lumbar spine pathology and lumbosacral plexopathy. Specifically, this paper delves into spine and plexus anatomy, delineates the clinical assessment of both pathologies, and highlights powerful diagnostic tools in the hopes of bolstering appropriate diagnosis and treatment. Lastly, this review will describe emerging treatment options for both pathologies in the preclinical and clinical realms, with a special emphasis on regenerative nerve therapies.

Imaging in the Diagnosis of Nonspecific Pyogenic Spondylodiskitis

The prevalence of nonspecific pyogenic spondylodiskitis, associated with both a high morbidity and a high mortality, has increased in the last few decades. The diagnosis is often delayed because of the nonspecific clinical manifestation at the early stage. The reliability of radiographs is limited, particularly in early stage after the onset of infection. Computed tomography (CT) can reliably assess the bony condition with the possibility of spatial visualization. Contrast enhancement supports the detection of affected soft tissue. Magnetic resonance imaging (MRI) continues to be the gold standard in the diagnosis of spondylodiskitis. Sophisticated investigation protocols supported by gadolinium enhancement secure the diagnosis. MRI has a high resolution without radiation exposure. Different nuclear investigation techniques extend the diagnostic options. Reports of 18F-fluorodeoxyglucose-positron emission tomography (18-FDG-PET) are particularly promising to confirm the diagnosis. The drawback of the reduced image quality with respect to detailed anatomical information can be overcome by a combined simultaneous acquisition of CT or MRI. With respect to one of the greatest challenges, the differentiation between degenerative changes (Modic type 1) and infection at an early stage using differentiated MRI protocols and FDG-PET is promising. This overview presents a concise state-of-the-art look at radiologic investigations in case of suspected nonspecific pyogenic spondylodiskitis with the focus on a pragmatic approach.

Brucellosis with rare complications and review of diagnostic tests: a case report

BACKGROUND

Brucellosis is one of the most common zoonotic diseases in the world. Osteoarticular complications, especially vertebral system involvement, are most commonly reported. However, reports and coreports of pulmonary complications and thoracal spondylodiscitis and epidural abscess are rare.

CASE PRESENTATION

Spondylodiscitis was detected at the T11-12 vertebral level, followed by epidural and paravertebral abscess, and then empyema was detected in a 17-year-old Asian female patient without any additional disease. The patient had used various antibiotics and the disease could not be proven bacteriologically. Also, the Rose Bengal test was negative. However, serologically high titer Brucella positivity was detected in the blood and pleural fluid sample. Drainage was required for bilateral empyema. Disease duration prolonged due to multiple complications. The patient was cured with combined long-term treatment for brucellosis.

CONCLUSIONS

Although some are rare, brucellosis is a zoonotic disease that can cause many complications. The gold standard for diagnosis is the growth of bacteria in blood culture or tissue culture. However, isolation of the microorganism can be very difficult. Clinical suspicion and serological tests are important guides.

Utility of disc space aspirate cell counts and differentials in the diagnosis of native vertebral osteomyelitis

Background: Aspiration of intervertebral disc space is often done to confirm the diagnosis of native vertebral osteomyelitis. A study has not been done examining the utility of cell counts and differentials of the aspirated fluid in diagnosing native vertebral osteomyelitis (NVO). Methods: In this feasibility study, we prospectively enrolled patients with a suspected diagnosis of NVO referred to the Division of Neuroradiology for image-guided needle aspiration of the intervertebral disc. In this study, manual cell count was done on the aspirated fluid, followed by a differential cytospin technique and touch prep. We obtained demographic, lab, and microbiologic data and used the receiver operating curve (ROC) for statistical analysis. Results: Over 12 months, we performed 17 aspirates on 14 patients. The median age was 70.5 years (range: 45-77). The median manual cell count on the aspirated fluid was 52 cells  µ L - 1 (range: 0-6656), the median neutrophil percentage on the touch prep slide was 73 % (range: 5 %-100 %), and the median neutrophil percentage on the cytospin slide was 82 % (range: 0 %-100 %). Routine bacterial cultures were positive in five cases, and the 16S ribosomal RNA gene polymerase chain reaction was positive in two cases. The optimal cutoff for a cell count of 104 total nucleated cells offered a sensitivity and specificity of 86 %, and a neutrophil cutoff of 83 % was associated with a 71 % sensitivity and specificity. Conclusion: An image-guided aspirated specimen leukocyte differential of ≥ 83  % neutrophils or a leukocyte count of ≥ 104   µ L - 1 was a sensitive and specific test for diagnosing patients with suspected NVO. Additionally, more extensive studies are warranted to confirm the findings.

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.

A Combined Diagnosis and Treatment Algorithm for Spine Infection Management: A Single-Center Experience

Background and objective

Spinal infection (SI) is an infectious disease affecting the vertebral column, spinal cord, and adjacent structures. The infection can occur following interventions or spontaneously. The aim of this study was to highlight the importance of employing a methodological approach for the accurate and rapid diagnosis of SI and to share information on the most effective treatment method, which involves using a diagnostic-treatment algorithm that can help with SI management.

Methodology

This study included 50 patients diagnosed with SI between 2016 and 2020. The treatment follow-up period was limited to six months, and the study was conducted as a retrospective cohort analysis. The sample consisted of 22 female patients and 28 male patients, and the mean age of the patients was 50.2 years. All patients received diagnosis and treatment according to the algorithm described in this article.

Results

In the study group, 60% of patients had an infection in the lumbar spine, 4% in the thoracal spine, 12% in the cervical spine, and 8% in the sacral spine. Previously operated patients were diagnosed on the 30.16th day on average. A total of 19 patients (38%) had no history of undergoing surgery. Radiologically, the most common finding was spondylodiscitis/discitis (32%). Osteomyelitis was detected in one (2%) patient. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most commonly isolated organism in culture results and was detected in 13 patients (26%). The culture results of 12 patients (24%) were negative. The number of patients with active SI who were unstable and stabilized at the time of diagnosis was 11 (22%), and stabilization materials were removed in two patients (4%). In the 6th month of control, the patients did not have any complaints, signs of an infection, or unstable vertebral column.

Conclusions

We conclude that the combined algorithm we recommend for the diagnosis and treatment of patients with SI can prevent negative deviation and is an effective treatment for this condition.

Intermittent Short-Term Infusion vs. Continuous Infusion of Piperacillin: Steady State Concentrations in Porcine Cervical Spine Tissue Evaluated by Microdialysis

Background: Piperacillin is a central drug in the treatment of Pseudomonas aeruginosa spondylodiscitis. Intermittent short-term infusion (STI) remains standard treatment in most centres, although the application of continuous infusion (CI) has shown promising results in other clinical settings. We aimed to evaluate time above the minimal inhibitory concentration (fT > MIC) of the free fraction of piperacillin in steady state conditions in porcine cervical spine tissue following CI and STI using microdialysis with MIC targets of 4, 8, and 16 μg/mL. Methods: 16 female pigs were randomized to receive piperacillin/tazobactam as STI (4/0.5 g every 6 h) or CI (4/0.5 g as a bolus followed by 12/1.5 g) for 18 h. Microdialysis catheters were placed for sampling of piperacillin concentrations from the intervertebral disc, vertebral cancellous bone, paravertebral muscle, and adjacent subcutaneous tissue during the third dosing interval (12−18 h). Blood samples were collected as reference. Results: CI resulted in fT > MIC > 82% across all compartments and targets, except for intervertebral disc (37%) and vertebral cancellous bone (28%) at MIC = 16 μg/mL. In Group STI, >72% fT > MIC was reached for MIC = 4 μg/mL in all investigated compartments, while for MIC = 16 μg/mL only subcutaneous tissue exhibited fT > MIC > 50%. Conclusion: CI of piperacillin resulted in higher fT > MIC compared to STI infusion across the investigated tissues and targets. CI should therefore be considered in spondylodiscitis cases requiring piperacillin treatment.

An Isolated Radiographic Finding of Spontaneous Vertebral Osteomyelitis

Vertebral osteomyelitis (VO) is an infection of the vertebral body, most often arising secondary to hematogenous spread or contiguous spread from local soft tissue infection. Establishing a diagnosis of VO requires a high index of suspicion as patients often present with nonspecific symptoms such as pain of the affected vertebral segments along with leukocytosis and elevated inflammatory markers. Magnetic resonance imaging (MRI) has high sensitivity and specificity for detecting VO, even in the early phases of infection. Diagnosis is generally confirmed with blood cultures or vertebral biopsy demonstrating a culprit organism and treatment is tailored to the identified organism. However, some patients may have culture-negative VO that still necessitates antimicrobial treatment. Imaging alone may be an acceptable form of diagnosis that can allow for prompt empiric antibiotic therapy, reducing the need for invasive diagnostic measures. We present a case of a 46-year-old male with a past medical history of type 2 diabetes mellitus, hyperlipidemia, and prior transient ischemic attack (TIA). The patient presented with signs and symptoms of another TIA as well as new-onset neck and upper back pain. MRI in the neurologic workup demonstrated findings consistent with osteomyelitis of the C5 and C6 cervical vertebrae. Previous imaging showed no evidence of vertebral dysfunction. This patient presented with new-onset VO in the absence of systemic symptoms or elevation of inflammatory markers and no identified source of infection. Based on imaging and clinical presentation, empiric antibiotic treatment was initiated resulting in clinical improvement and resolution of VO on imaging. This case demonstrates an atypical presentation of VO and describes the benefit of MRI in recognizing infection in the absence of concurrent typical findings, which allowed for the initiation of empiric therapy.

A scoring system for the preoperative evaluation of prognosis in spinal infection: the MSI-20 score

BACKGROUND CONTEXT

Spinal infection (SI) is a life-threatening condition and its treatment remains challenging. Recent studies have supported early and aggressive surgery, but mortality still reaches 5% to 10% and it remains unclear, if an aggressive surgical strategy also applies for severely sick patients.

PURPOSE

The aim of this analysis was to generate an assessment score to predict mortality of SI in order to facilitate decision-making.

STUDY DESIGN

Retrospective risk factor analysis.

PATIENT SAMPLE

Two hundred fifty-two patients were retrospectively analyzed.

OUTCOME MEASURES

Physiologic measures, functional measures.

METHODS

Diagnosis was based on clinical presentation, imaging findings and inflammatory markers. Factors associated with mortality were identified by multivariate analysis, weighted according to their relative risk ratio (RR) and included in the novel assessment score.

RESULTS

Eight parameters were included: (1) BMI, (2) ASA score, (3) presence of sepsis, (4) age-adjusted Charlson Comorbidity Index, (5) presence and degree of renal failure, (6) presence of hepatopathy, (7) neurological deficits and (8) CRP levels at diagnosis. Each parameter was assigned a certain range of points, resulting in a maximum total score of 20. The mortality in spinal infection (MSI-20) score - indicating poorer status with higher values - was obtained for each patient and correlated with mortality.

CONCLUSION

An MSI-20 score of 11 or more points seems to identify the small group of patients being "too sick to undergo surgery," while early surgery can be recommended in the remainder (MSI-20 ≤10). Our results need to be confirmed in prospective studies, but may give guidance for indicating surgery even in rather sick and comorbid patients.

Assessment of Toxic Effects and Survival in Treatment Deescalation With Radiotherapy vs Transoral Surgery for HPV-Associated Oropharyngeal Squamous Cell Carcinoma: The ORATOR2 Phase 2 Randomized Clinical Trial

Importance

The optimal approach for treatment deescalation in human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCCs) is unknown.

Objective

To assess a primary radiotherapy (RT) approach vs a primary transoral surgical (TOS) approach in treatment deescalation for HPV-related OPSCC.

Design, Setting, and Participants

This international, multicenter, open-label parallel-group phase 2 randomized clinical trial was conducted at 9 tertiary academic cancer centers in Canada and Australia and enrolled patients with T1-T2N0-2 p16-positive OPSCC between February 13, 2018, and November 17, 2020. Patients had up to 3 years of follow-up.

Interventions

Primary RT (consisting of 60 Gy of RT with concurrent weekly cisplatin in node-positive patients) vs TOS and neck dissection (ND) (with adjuvant reduced-dose RT depending on pathologic findings).

Main Outcomes and Measures

The primary end point was overall survival (OS) compared with a historical control. Secondary end points included progression-free survival (PFS), quality of life, and toxic effects.

Results

Overall, 61 patients were randomized (30 [49.2%] in the RT arm and 31 [50.8%] in the TOS and ND arm; median [IQR] age, 61.9 [57.2-67.9] years; 8 women [13.6%] and 51 men [86.4%]; 31 [50.8%] never smoked). The trial began in February 2018, and accrual was halted in November 2020 because of excessive toxic effects in the TOS and ND arm. Median follow-up was 17 months (IQR, 15-20 months). For the OS end point, there were 3 death events, all in the TOS and ND arm, including the 2 treatment-related deaths (0.7 and 4.3 months after randomization, respectively) and 1 of myocardial infarction at 8.5 months. There were 4 events for the PFS end point, also all in the TOS and ND arm, which included the 3 mortality events and 1 local recurrence. Thus, the OS and PFS data remained immature. Grade 2 to 5 toxic effects occurred in 20 patients (67%) in the RT arm and 22 (71%) in the TOS and ND arm. Mean (SD) MD Anderson Dysphagia Inventory scores at 1 year were similar between arms (85.7 [15.6] and 84.7 [14.5], respectively).

Conclusions and Relevance

In this randomized clinical trial, TOS was associated with an unacceptable risk of grade 5 toxic effects, but patients in both trial arms achieved good swallowing outcomes at 1 year. Long-term follow-up is required to assess OS and PFS outcomes.

Trial Registration

Clinicaltrials.gov Identifier: NCT03210103.

Can we predict favourable quality of life after surgically treated vertebral osteomyelitis? Analysis of a prospective study

PURPOSE

Vertebral osteomyelitis (VO) is a severe clinical entity associated with significant morbidity and mortality. Several studies have showed that successful treatment of VO patients leads to significantly improved quality of life (QoL). Nevertheless, QoL levels of these patients remained below those of the general population. There are rarely studies focusing on predicting factors for favourable QoL after surgically treated VO. The aim of this study was to identify factors influencing positively the QoL of patients undergoing surgery for VO.

METHODS

We conducted a prospective monocentric study including surgically treated VO patients from 2008 to 2016. Data were collected before (T0) and 1 year (T1) after surgery. Primary outcome was favourable QoL defined as back pain with disability restricting normal life activity with a cutoff value ≥ 12 on Oswestry Disability Index (ODI).

ETHICS

Ethical approval was given by the Faculty of Medicine at the University of Cologne (09-182).

RESULTS

A total of 119 patients surviving 1 year after surgically treated VO were analysed. Favourable QoL was achieved in 35/119 patients. On multivariate analysis, younger age (hazard ratio = HR: 0.95; 95% CI 0.91-0.99; p = 0.022), lower albumin (HR: 0.9; 0.83-0.98; p = 0.019) an ASA score ≤ 2 (HR:4.24; 95%CI 1.42-12.68; p = 0.010), and a lower preoperative leg pain on the VAS (HR: 0.86; 95% CI 0.76-0.97; p = 0.018) were identified as independent risk factors for favourable QoL. Interestingly, the absence of neurological deficits was not predictive for a favourable outcome by means of QoL.

CONCLUSION

One-third of surgically treated VO patients (29%) in our cohort achieved favourable QoL by means of ODI. Our findings can facilitate an estimation of the prognosis when informing the patient before surgery, and underscore that spine disability questionnaires, such as ODI, measuring QoL, are mandatory to evaluate comprehensively the outcome of this entity.

Case Report: Diagnosis of Primary Klebsiella pneumoniae in Cervical Spine by Metagenomic Next-Generation Sequencing

Introduction

Spinal infection is a disease that affects the intervertebral disks or adjacent paravertebral tissue in the vertebral body. There are few reports of spinal infections caused by Klebsiella pneumoniae. Cervical spine infection by K. pneumoniae especially preoperative is extremely rare. Nowadays, metagenomic next-generation sequencing (mNGS) has led to the accurate and timely diagnoses of numerous infectious diseases.

Case Presentation

We described a case of a 64-year-old woman, with a chief complaint of neck, shoulder, and upper limb pain for 10 days. The patient had symptoms of abscess compression before surgery, and inflammatory indicators such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin (PCT) were significantly elevated. The patient's imaging suggested cervical infectious lesions, and the patient had no symptoms of tuberculosis poisoning, and the blood samples associated with tuberculosis were negative. The patient was diagnosed with cervical suppurative infection before surgery. For the patient who failed conservative treatment and had abscess compression, we performed anterior cervical surgery to remove the lesion at an early stage and collected intraoperative specimens for culture and mNGS. Postoperative antibiotic treatment was adjusted according to the etiology and drug sensitivity.

Conclusion

This case suggests that the clinical symptoms of K. pneumoniae infection are not typical and the imaging examination lacks specificity. When the clinical diagnosis of etiology is not clear or there are symptoms such as abscess compression, early surgical specimens can be collected for culture and mNGS to identify the pathogen, and postoperative sensitive antibiotics can be used to continue treatment. This helps to identify the cause as early as possible, treat it effectively early, relieve symptoms, prevent complications, and keep the spine stable.

The Burden of Vertebral Osteomyelitis—An Analysis of the Workforce before and after Treatment

Although vertebral osteomyelitis (VO) has a major impact on morbidity, functional status, and quality of life, data concerning the influence on the patient’s ability to work (ATW) are lacking. Therefore, the aim of this study was to analyze the work status after VO-treatment as well as risk factors associated with loss of the ATW. We conducted a post-hoc analysis of data from a prospective VO-registry (2008–2019) supplemented by workforce data. Primary endpoint was the work status after one year (T1). Univariate analysis comparing patients’ characteristics “at-work” versus “not-at-work” at T1 was performed. Of a total of 335 VO-patients, n = 52 (16%) were part of the workforce at time of diagnosis (T0), of which 22 (42%) failed to be part of the workforce at T1. A higher number of comorbidities and a body mass index (BMI) < 25 kg/m² were associated with a reduced ATW. VO in working age patients is a debilitating condition and associated with reduced patients’ ATW. Patients engaged in heavy physical work mostly had a BMI < 25 kg/m² and therefore were more severely affected and no longer able to keep their workforce. More support in retraining should be offered after successful treatment to maintain ATW and reduce the socio-economic burden.

Clinical results of a lamina with spinous process and an iliac graft as bone grafts in the surgical treatment of single-segment lumbar pyogenic spondylodiscitis: a retrospective cohort study

Background

A retrospective study compared the results of a lamina with spinous process (LSP) and an iliac graft (IG) as bone grafts in single-segment lumbar pyogenic spondylodiscitis (LPS) through one-stage-posterior-only approach with radical debridement and instrumentation.

Methods

A LSP was placed in 17 patients (group A), and an IG was implemented in 20 patients (group B). The surgery time, surgery hemorrhage, hospital stay, drainage, and follow-up (FU) were recorded and compared. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, visual analogue scale (VAS), Oswestry Disability Index (ODI), segmental angle, intervertebral height and bony fusion time were compared preoperatively and at the final FU.

Results

All patients were followed-up for a mean of 27.94 ± 2.35 months in group A and 30.29 ± 1.89 months in group B, without a difference. The mean age was younger in group A than in group B (P < 0.05). The surgery time, surgery hemorrhage, and hospitalization cost were lower in group A than in group B (P < 0.05), except for the hospital stay and drainage time. 10 patients in group A had fever and 12 patients in group B. The ESR, CRP level, VAS and ODI scores were significantly decreased, and no significant differences were found between the groups at the final FU. The distribution of bacterial agents in blood culture was 1 case of Aerobacter cloacae, 2 of Staphylococcus aureus, 2 of Escherichia coli, and 1 of Streptococcus viridis in group A and 1 of S. aureus, 1 of Staphylococcus warneri and 2 of Klebsiella pneumoniae in group B. Pyogenic infection was observed in the pathological findings of all patients. No significant difference was found in the mean segmental angle or mean intervertebral height preoperation and at the final FU.

Conclusion

The use of LSP could be an effective bone grafting for surgical management for the LPS while surgery is proposed as a good management strategy for single-segment LPS in carefully selected patients.

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.

Osteomyelitis of the spine: treatments and future directions

BACKGROUND

Osteomyelitis of the spine is a serious condition that has been increasing with the intravenous drug pandemic and aging population. Multiple different organisms can cause osteomyelitis and mainstay of treatment is early recognition and antibiotics. The course can sometimes be indolent leading to delayed presentations. Once suspected, comprehensive workup and initiation of management should be employed. In rare circumstances, surgical evacuation or deformity correction is indicated. Continued antibiotic treatment should be considered post-operatively.

METHODS

Emerging treatment solutions are being developed to help target osteomyelitis in a more effective manner. In this review, we highlight the epidemiology and pathophysiology of spinal osteomyelitis. We overview the diagnostic workup and treatment options. Finally, we present new options that are currently being investigated and are on the near horizon.

CONCLUSION

This review offers a user friendly resource for clinicians and researchers regarding osteomyelitis of the spine and will serve as a catalyst for further discovery.

CT-Guided Needle Biopsy in Vertebral Osteomyelitis: Study of Factors That Could Influence in Culture Yield

OBJECTIVE

The aim of this study was to analyze which are the main factors that could influence the result of a CT guided biopsy in vertebral osteomyelitis (VO) patients.

METHODS

A single center retrospective observational study was performed including adult patients who had been diagnosed with VO and undergone CT guided needle biopsy from January 2010 to January 2020. Demographical features, concurrent diseases, laboratory findings, microbiological diagnosis, radiological data, medical complications, antibiotic exposure were compiled. Multivariate analysis was performed with a logistic regression comparing the patients depending on the culture result.

RESULTS

Seventy-seven patients were included in the study. Baseline characteristics were comparable between groups. Sample culture was positive in 43 cases (56%). Microorganism isolated were gram+(72%), gram-(14%), mycobacteria (7%) and fungi (7%). Delay in the procedure, antibiotic exposure and blood culture positivity were also similar among both groups. The biopsy results were not influenced by the CRP value, the presence of fever nor antibiotic exposure. The longer duration of back pain was associated to a lower probability of a positive culture.

CONCLUSIONS

In conclusion, our study displays an acceptable reliability of CT guided needle biopsy in VO patients, even in cases under antibiotic treatment. The presence of fever or CRP values did not predict a positive culture. Delay in diagnosis could impact negatively on culture yield.

The effect of instrumentation staging on patient outcomes in pyogenic vertebral osteomyelitis: A systematic review

Background

Pyogenic vertebral osteomyelitis is a bacterial infection of the vertebral body that is often treatable with antibiotics, but some cases require additional surgical debridement of the infected tissue. Instrumentation is often utilized for stabilization of the spine as part of the surgical treatment, but controversy remains over the relative risks and benefits of acute instrumentation performed simultaneously with debridement versus delayed instrumentation performed days or weeks after debridement. The purpose of this review was to investigate the relative effects of acute and delayed instrumentation in treatment for pyogenic vertebral osteomyelitis on patient outcomes.

Methods

A PRISMA-compliant systematic literature review was conducted to identify studies published between January 1, 1997 and July 23, 2021. Studies were screened for pre-defined inclusion and exclusion criteria. The primary outcome of interest was reinfection. Other outcomes of interest included neurological status, pain, progression of kyphosis, fusion, hardware failure, length of hospitalization, and mortality at two years. Due to the limited multi-armed studies available that distinguish between patients with acute and delayed instrumentation, inferential statistics were not performed, and data are expressed as descriptive statistics.

Results

A total of 9 studies met our inclusion criteria, comprising 299 patients, including 113 (37.8%) with surgical treatment without fixation, 138 (46.2%) with acute instrumentation, and 48 (16.1%) with delayed instrumentation. Reinfection rates were 60.0% (15/25) for surgical treatment without fixation, 28.6% (2/7) for the acute instrumentation, and 14.3% (1/7) for the delayed instrumentation group. Pain was present after surgery in 52.0% (13/25) of the surgical treatment without fixation group, 14.3% (1/7) of the acute instrumentation group, and 0% (0/7) of the delayed instrumentation group.

Conclusions

No major differences in patient outcomes were apparent between acute and delayed instrumentation groups. Further research is needed to determine whether instrumentation staging has a significant impact on patient outcomes.

Delayed diagnosis of osteodiscitis in an adolescent athlete: a case report

BACKGROUND

Vertebral osteomyelitis (OM) is an infectious condition of bone caused by an infecting organism, most commonly Staphylococcus aureus (S. aureus). Though rare in adolescents, it is important to remember that this population has vascularized intervertebral discs prior to skeletal maturity and, therefore, is more susceptible to an osteodiscitis infection.

PURPOSE

To determine the possible factors that lead to a delayed diagnosis of osteodiscitis compared to an early diagnosis in an adolescent athlete.

SUMMARY

This case provides a unique example of osteodiscitis in an adolescent rowing athlete where an infected heel blister was the only indication toward a diagnosis. Early diagnosis and successful management of osteodiscitis are dependent on recognizing constitutional and non-constitutional signs and symptoms of infection.

CLINICAL RELEVANCE

In sport, when skin barriers may be compromised more readily, the risk of infection should be considered in the differential diagnosis of unprovoked back pain.