Spinal infections in older people: an analysis of demographics, presenting features, microbiology and outcomes

Understanding clinical complexity in organ and organizational systems: Challenges local and global

INTRODUCTION

Complexity in healthcare systems has been arbitrarily defined as tasks or systems ranging from complicated to intractable, with a general view of these not being 'simple'. Complexity in healthcare systems in first-world countries has been well elucidated, however, data from third-world countries is still scant. MATERIALS AND METHODS: We present four cases each from three different organ systems-chronic kidney disease, alcohol use disorder, and heart failure-in the backdrop of our healthcare organization. We present our analysis of the complexities faced clinically and, in our local healthcare system which led to these events.

RESULTS

Analysis of these cases showed that patients with chronic kidney disease had vertebral-spinal pathologies due to poor infection control measures during haemodialysis. All these patients were young with a long history of secondary hypertension. In patients with alcohol use disorder, a common theme of how government regulations and peer pressure promote alcohol use is analysed. In the four patients with unexplained heart failure, vascular health is viewed as a fractal dimension and the various factors affecting vascular health are elaborated.

CONCLUSION

Complexities exist clinically in making a diagnosis, and organizationally, in the variables and nodes dictating patient outcomes. Clinical complexities cannot be simplified but have to be navigated in an optimized way to improve clinical outcomes.

Ureteric stent associated spondylodiscitis

This case report describes a clinical presentation of spondylodiscitis, following an emergency ureteric stent placement for an infected and obstructed kidney in a woman in her late 70s who presented with right flank pain, raised inflammatory markers and an acute kidney injury. Non-contrast CT kidney, ureters and bladder (KUB) revealed a 9 mm obstructing stone and prompt decompression with a JJ stent was performed. Although the urine culture showed no growth at first, an extended spectrum beta-lactamase Escherichia coli was found in a subsequent urine culture after discharge. Postoperatively, the patient described a novel, worsening lower back pain and had persistently elevated inflammatory markers. An MRI revealed spondylodiscitis of L5/S1, for which she was treated with a 6-week course of antibiotics, and she has made a good but slow recovery. This case shows the unusual finding of spondylodiscitis postureteric stent placement and clinicians should be aware of this rare complication.

Spondylodiscitis in Geriatric Patients: What Are the Issues?

STUDY DESIGN

Review article.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Application of metagenomic next-generation sequencing in the detection of pathogens in spinal infections

BACKGROUND CONTEXT

The precise diagnosis and treatment of spinal infections (SI) remains challenging for spine surgeons. Identifying the pathogens of SI through metagenomic next-generation sequencing (mNGS) may be a key approach to addressing this challenge.

PURPOSE

To evaluate the accuracy and applicability of mNGS in determining the etiology of SI.

STUDY DESIGN

Diagnostic test study.

PATIENT SAMPLE

Twenty-five patients who had a clinical suspicion of SI and underwent mNGS testing.

OUTCOME MEASURES

The specificity, sensitivity, and time cost of mNGS and bacterial culture were compared. Clinical outcomes were assessed using the numeric rating scale (NRS) score, Oswestry Disability Index (ODI), and the Japanese Orthopedic Association (JOA) score. Demographic data and laboratory results (blood cell count (WBC), erythrocyte sedimentation rate (ESR), neutrophil percentage (NEUT%), and C-reactive protein level (CRP) were also evaluated.

METHODS

In this retrospective study, samples were obtained from 25 eligible patients via surgery or CT-guided puncture and subjected to histopathological examination, bacterial culture, and mNGS. The sensitivity and specificity of the bacterial cultures and mNGS were calculated with respect to the histopathological results as a reference. Postoperative antibiotics or antituberculosis drugs were administered on the basis of mNGS results, combined with clinical manifestations, imaging examination, and histopathology. The changes of clinical outcomes and laboratory results after treatment were observed.

RESULTS

Of the 25 patients, 21 had a positive pathology, of which 10 showed a tuberculous pathology, and the remaining 11 showed a nontuberculous inflammatory pathology. The sensitivity of mNGS was higher than that of the bacterial culture. However, the difference in specificity between bacterial culture and mNGS was not significant. Moreover, the time needed to perform mNGS was significantly lower than that of bacterial culture and pathology. All patients were followed up for more than three months, and CRP and NEUT% significantly decreased by three months after treatment. There was no significant difference in WBC and ESR. The ODI, NRS and JOA scores were significantly improved after treatment.

CONCLUSION

Metagenomic next-generation sequencing technology can play an important role in the detection of pathogens in SI and should be further investigated and applied in future studies.

Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications

Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.

Red flags for the early detection of spinal infection in back pain patients

BACKGROUND

Red flags are signs and symptoms that are possible indicators of serious spinal pathology. There is limited evidence or guidance on how red flags should be used in practice. Due to the lack of robust evidence for many red flags their use has been questioned. The aim was to conduct a systematic review specifically reporting on studies that evaluated the diagnostic accuracy of red flags for Spinal Infection in patients with low back pain.

METHODS

Searches were carried out to identify the literature from inception to March 2019. The databases searched were Medline, CINHAL Plus, Web of Science, Embase, Cochrane, Pedro, OpenGrey and Grey Literature Report. Two reviewers screened article texts, one reviewer extracted data and details of each study, a second reviewer independently checked a random sample of the data extracted.

RESULTS

Forty papers met the eligibility criteria. A total of 2224 cases of spinal infection were identified, of which 1385 (62%) were men and 773 (38%) were women mean age of 55 (± 8) years. In total there were 46 items, 23 determinants and 23 clinical features. Spinal pain (72%) and fever (55%) were the most common clinical features, Diabetes (18%) and IV drug use (9%) were the most occurring determinants. MRI was the most used radiological test and Staphylococcus aureus (27%), Mycobacterium tuberculosis (12%) were the most common microorganisms detected in cases.

CONCLUSION

The current evidence surrounding red flags for spinal infection remains small, it was not possible to assess the diagnostic accuracy of red flags for spinal infection, as such, a descriptive review reporting the characteristics of those presenting with spinal infection was carried out. In our review, spinal infection was common in those who had conditions associated with immunosuppression. Additionally, the most frequently reported clinical feature was the classic triad of spinal pain, fever and neurological dysfunction. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Evaluation of Challenges in Diagnosis of Spontaneous Subacute Pyogenic Spondylodiscitis in Immunocompetent Patients: Experiences from a Tertiary Care Center

Study Design

Prospective clinical study.

Purpose

We evaluated the challenges faced during diagnosis and management of patients with subacute pyogenic discitis and discussed various clues in clinical history, radiologic and hematologic parameters of these patients that helped in establishing their diagnosis.

Overview of Literature

Present literature available shows that in patients with subacute spondylodiscitis and infection with less virulent organisms, the clinical picture often is confusing and the initial radiologic and hematologic studies do not contribute much toward establishing the diagnosis.

Methods

Demographic pattern, predisposing factors, clinical presentation, comorbidities, microbiology, treatment, neurologic recovery, and complications of 11 patients were prospectively reviewed regarding their contribution toward the conformation of diagnosis of subacute pyogenic discitis.

Results

Mean age at presentation was 46.0 years with average preoperative Oswestry Disability Index and Visual Analog Scale scores of 83.4 and 7.18, respectively. Mean follow-up duration was 12.0 months. The most common site of infection was the lumbar spine, followed by the thoracic spine (n=1). Infective organisms were isolated in only 45% of cases. Staphylococcus aureus was the most common causative organism isolated.

Conclusions

Diagnosing subacute spondylodiscitis in a patient presenting with subacute low backache poses a diagnostic challenge. Clinical and radiologic picture are deceiving, and bacteriologic results often are negative, further complicating the picture. A detailed medical history along with clinical, radiologic, and biochemical parameters prevents missing the diagnosis. Serial serum Creactive protein and alkaline phosphatases were more reliable blood parameters in cases of subacute presentation.

Delayed diagnosis of odontoid peg osteomyelitis with bilateral X and XII cranial nerve palsies

Upper cervical osteomyelitis is rare. Its presenting features are fever and neck pain, but rarely it can involve lower nerves. MRI is the main imaging modality, but it is difficult to interpret due to the unique anatomy of C1 and C2 vertebra and complex intervertebral joint. We describe a case of a 67-year-old woman, who presented with the complaint of loss of voice, neck pain and fever for 5 days. Despite repeated imaging of neck, the diagnosis was not reached. As the patient's condition continued to deteriorate, clinical signs of bilateral 10th and 12th cranial nerve paralysis appeared and lead to a focused workup for base of skull pathology. Discussion with the radiologist helped guide the imaging protocol, which leads to the correct diagnosis being made. Treatment was tailored by blood cultures and available images. Temporary immobilisation with a cervical collar and a total of 12 weeks of antibiotics lead to complete remission.

Spondylodiscitis in end-stage renal disease: a systematic review

OBJECTIVE

Discitis and osteomyelitis are seen in end-stage renal disease (ESRD) patients due to repeated vascular access for hemodialysis and urinary tract infections leading to recurrent bacteremia. Discitis and osteomyelitis are underdiagnosed due to the nonspecific initial presentation of back pain. In this article, we review the literature for better understanding of the problem and the importance of early diagnosis by primary care physicians and nephrologists. In addition, we discuss the decision-making, follow-up, management, and neurological outcomes.

METHODS

A detailed PubMed search was performed using the following terms: "end stage renal disease (ESRD)" and "chronic renal failure (CRF)," combined with "spine infections," "spondylodiscitis," "discitis," and "osteomyelitis." Search results were limited to articles written in English, case reports, and case series from 1973 to 2012. Editorials, reviews, and commentaries were excluded. Only studies involving human patients were included. The authors also included 4 patients from their own patient population.

RESULTS

A total of 30 articles met the inclusion criteria. Including the 4 patients from the authors' patient population, 212 patients with spine infections and maintenance dialysis were identified. The patients' ages ranged from 38 to 78 years. The duration of dialysis ranged from a few days to 16 years. The time from onset of back pain to diagnosis ranged from 3 days to 6 months. The most common causative organism was Staphylococcus aureus, followed by Staphylococcus epidermidis and gram-negative bacteria. Most of the patients were treated with antibiotics alone (76.8%), although surgery was indicated when patients presented with neurological deficits (p < 0.011). Approximately one-quarter of the patients developed neurological deficits, with devastating consequences. Fever and neurological deficits at presentation, culture positive for methicillin-resistant S. aureus, and age > 65 years were highly correlated with mortality in our analysis.

CONCLUSIONS

Several risk factors lead to failure of antibiotics and progression of disease in patients with ESRD. Challenges to diagnosis include vague presenting symptoms, co-existing destructive spondyloarthropathy, poor immune response, chronic elevations of inflammatory markers, and recurrent bacteremia. Infectious processes are more likely to cause permanent neurological deficits than transient deficits. The authors recommend close observation and serial imaging of these patients for early signs of neurological deficits. Any signs of disease progression will require aggressive surgical debridement.

Musculoskeletal Infections in the Emergency Department

Bone and joint infections are potentially limb-threatening or even life-threatening diseases. Emergency physicians must consider infection when evaluating musculoskeletal complaints, as misdiagnosis can have significant consequences. Patients with bone and joint infections can have heterogeneous presentations with nonspecific signs and symptoms. Staphylococcus aureus is the most commonly implicated microorganism. Although diagnosis may be suggested by physical examination, laboratory testing, and imaging, tissue sampling for Gram stain and microbiologic culture is preferable, as pathogen identification and susceptibility testing help optimize long-term antibiotic therapy. A combination of medical and surgical interventions is often necessary to effectively manage these challenging infections.

Pyogenic Spondylodiscitis of the Thoracic Spine: Outcome of 1-Stage Posterior Versus 2-Stage Posterior and Anterior Spinal Reconstruction in Adults

OBJECTIVE

The aim of this study was to compare the clinical, radiologic, and functional outcomes of a 1-stage posterior treatment versus a 2-stage posterior-anterior treatment in patients with pyogenic thoracic spondylodiscitis.

METHODS

A 1-stage posterior debridement, stabilization, and fusion with titanium-coated polyetheretherketone (PEEK) or mesh cage through a dorsolateral approach was performed in group A. A 2-stage procedure with initial posterior stabilization and debridement and second-stage fusion with a PEEK cage or mesh cage was performed with an anterior approach in group B. Clinical outcomes included Oswestry Low Back Pain Disability Questionnaire and visual analog scale score. Radiologic outcomes included fusion rate and kyphotic angle correction. Secondary variables included pathogens, complications, blood loss, and operative time.

RESULTS

One-level spondylodiscitis was treated surgically in the thoracic spine of 47 patients: 25 patients in group A and 22 patients in group B. The most frequent segment was T12-L1 (27%). There was a significantly longer operative time and greater blood loss (P > 0.001) in group B. At last follow-up, sagittal profile reconstruction was significantly better (P > 0.05) in group B. Both groups showed similar radiologic results with fusion in 92% of cases. Improved clinical outcomes, pain, and quality of life were achieved in both groups with no significant differences between the 2 groups.

CONCLUSIONS

Better reconstruction of the sagittal profile was achieved in the posterior-anterior-treated group, but this did not affect the clinical outcome. No significant differences were found in the clinical and functional outcomes between the 2 groups. Posterior-anterior combined treatment should be considered in cases of large anterior defects if a posterior reconstruction is inadequate.

Treatment of lumbar discitis using silicon nitride spinal spacers: A case series and literature review

INTRODUCTION

Septic infection of a lumbar intervertebral disc is a serious disorder which is often difficult to diagnose and appropriately treat because of the rarity of the disease, the varied presentation of symptoms, and the frequency of low-back pain within the overall population. Its etiology can be pyogenic, granulomatous, fungal, or parasitic; its incidence is rising due to increased patient susceptibility and improved diagnostic tools. Conservative treatments involve antibiotics, physical therapy, and/or immobilization. More aggressive management requires discectomy, debridement, and spinal fusion in combination with local and systemic antibiotic administration.

PRESENTATION OF CASES

Presented here are two case studies of lumbar pyogenic discitis associated with Escherichia coli and Candida albicans infections. Both required single-level anterior discectomy followed by spinal fusion using an antimicrobial silicon nitride (Si3N4) spacer for stabilization without instrumentation. Localized antibiotics were used for only one of the patients. Follow-up CT and MRI scans showed that the infections had been resolved with no recurrence of symptoms.

DISCUSSION

Si3N4 is a relatively new spinal spacer material. It was utilized in these two cases because it reportedly provides a local environment which promotes rapid arthrodesis while resisting bacterial adhesion and biofilm formation. It is also highly compatible with X-ray, MRI, and CT imaging modalities. These properties were particularly attractive for these two cases given the patients' histories, presentation of symptoms, and the decision to forego instrumentation.

CONCLUSION

The use of Si3N4 as an antimicrobial spacer may lead to improved outcomes for patients with pyogenic discitis of the lumbar spine.

Spondylodiscitis revisited

Spondylodiscitis may involve the vertebral bodies, intervertebral discs, paravertebral structures and spinal canal, with potentially high morbidity and mortality rates.

A rise in the susceptible population and improved diagnosis have increased the reported incidence of the disease in recent years.

Blood cultures, appropriate imaging and biopsy are essential for diagnosis and treatment.

Most patients are successfully treated by conservative means; however, some patients may require surgical treatment.

Surgical indications include doubtful diagnosis, progressive neurological deficits, progressive spinal deformity, failure to respond to treatment, and unresolved pain.

Cite this article: EFORT Open Rev 2017;2:447–461. DOI: 10.1302/2058-5241.2.160062