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Thavarajasingam SG, Vemulapalli KV, Vishnu K S, Ponniah HS, Vogel ASM, Vardanyan R, Neuhoff J, Kramer A, Shiban E, Ringel F, Demetriades AK, Davies BM. Conservative versus early surgical treatment in the management of pyogenic spondylodiscitis: a systematic review and meta-analysis. Sci Rep 2023; 13:15647. [PMID: 37730826 PMCID: PMC10511402 DOI: 10.1038/s41598-023-41381-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023] Open
Abstract
Spondylodiscitis is the commonest spine infection, and pyogenic spondylodiscitis is the most common subtype. Whilst antibiotic therapy is the mainstay of treatment, some advocate that early surgery can improve mortality, relapse rates, and length of stay. Given that the condition carries a high mortality rate of up to 20%, the most effective treatment must be identified. We aimed to compare the mortality, relapse rate, and length of hospital stay of conservative versus early surgical treatment of pyogenic spondylodiscitis. All major databases were searched for original studies, which were evaluated using a qualitative synthesis, meta-analyses, influence, and regression analyses. The meta-analysis, with an overall pooled sample size of 10,954 patients from 21 studies, found that the pooled mortality among the early surgery patient subgroup was 8% versus 13% for patients treated conservatively. The mean proportion of relapse/failure among the early surgery subgroup was 15% versus 21% for the conservative treatment subgroup. Further, it concluded that early surgical treatment, when compared to conservative management, is associated with a 40% and 39% risk reduction in relapse/failure rate and mortality rate, respectively, and a 7.75 days per patient reduction in length of hospital stay (p < 0.01). The meta-analysis demonstrated that early surgical intervention consistently significantly outperforms conservative management in relapse/failure and mortality rates, and length of stay, in patients with pyogenic spondylodiscitis.
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Affiliation(s)
- Santhosh G Thavarajasingam
- Faculty of Medicine, Imperial College London, Reynolds Building, St Dunstan's Road, London, W6 8RP, UK.
- Department of Academic Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Healthcare Trust, Cambridge, UK.
- Imperial Brain and Spine Initiative, Imperial College London, London, UK.
- Spondylodiscitis Study Group, EANS Spine Section, Hamburg, Germany.
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany.
| | - Kalyan V Vemulapalli
- Faculty of Medicine, Imperial College London, Reynolds Building, St Dunstan's Road, London, W6 8RP, UK
- Imperial Brain and Spine Initiative, Imperial College London, London, UK
| | - Sajeenth Vishnu K
- Faculty of Medicine, Imperial College London, Reynolds Building, St Dunstan's Road, London, W6 8RP, UK
- Imperial Brain and Spine Initiative, Imperial College London, London, UK
| | - Hariharan Subbiah Ponniah
- Faculty of Medicine, Imperial College London, Reynolds Building, St Dunstan's Road, London, W6 8RP, UK
- Imperial Brain and Spine Initiative, Imperial College London, London, UK
| | - Alexander Sanchez-Maroto Vogel
- Imperial Brain and Spine Initiative, Imperial College London, London, UK
- Faculty of Medicine, Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Robert Vardanyan
- Faculty of Medicine, Imperial College London, Reynolds Building, St Dunstan's Road, London, W6 8RP, UK
- Department of Academic Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Healthcare Trust, Cambridge, UK
- Imperial Brain and Spine Initiative, Imperial College London, London, UK
| | - Jonathan Neuhoff
- Center for Spinal Surgery and Neurotraumatology, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
- Spondylodiscitis Study Group, EANS Spine Section, Hamburg, Germany
| | - Andreas Kramer
- Department of Neurosurgery, Universitätsmedizin Mainz, Mainz, Germany
- Spondylodiscitis Study Group, EANS Spine Section, Hamburg, Germany
| | - Ehab Shiban
- Department of Neurosurgery, Universitätsklinikum Augsburg, Augsburg, Germany
- Spondylodiscitis Study Group, EANS Spine Section, Hamburg, Germany
| | - Florian Ringel
- Department of Neurosurgery, Universitätsmedizin Mainz, Mainz, Germany
- Spondylodiscitis Study Group, EANS Spine Section, Hamburg, Germany
| | - Andreas K Demetriades
- Edinburgh Spinal Surgery Outcome Studies Group, Department of Neurosurgery, Division of Clinical Neurosciences, NHS Lothian, Edinburgh University Hospitals, Edinburgh, UK
- Spondylodiscitis Study Group, EANS Spine Section, Hamburg, Germany
| | - Benjamin M Davies
- Department of Academic Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Healthcare Trust, Cambridge, UK
- Spondylodiscitis Study Group, EANS Spine Section, Hamburg, Germany
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Pluemer J, Freyvert Y, Pratt N, Robinson JE, Cooke JA, Tataryn ZL, Godolias P, Daher ZA, Oskouian RJ, Chapman JR. An Assessment of the Safety of Surgery and Hardware Placement in de-novo Spinal Infections. A Systematic Review and Meta-Analysis of the Literature. Global Spine J 2023; 13:1418-1428. [PMID: 36510352 PMCID: PMC10416600 DOI: 10.1177/21925682221145603] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Primary objectives were outcomes comparison of instrumented surgery used for de-novo spinal infections in terms of infection recurrence, reoperations, primary failure, mortality, and length of stay relative to non-instrumented surgery. Secondary objectives were outcomes for surgical and non-surgical treatment of de-novo spinal infections regarding recurrence of infection, mortality, quality of life, and length-of-stay. METHODS A systematic literature review was performed using the PubMed database. Studies comparing outcome variables of patients with de-novo spinal infections (DNSI) treated with and without instrumentation and surgical versus non-surgical treatment were included. Studies primarily focusing on epidural abscesses or non-de-novo infections were excluded. A meta-analysis was performed for infection recurrence, reoperation, primary treatment failure, mortality, and quality-of-life parameters. RESULTS A total of 17 retrospective studies with 2.069 patients met the inclusion criteria. 1.378 patients received surgical treatment with or without instrumentation; 676 patients were treated non-surgically. For the comparison of instrumented to non-instrumented surgery Odds-Ratios were .98 (P = .95) for infection recurrence, .83 (P = .92) for primary failure, .53 (P = .02) for mortality and .32 (P = .05) for reoperation. For the comparison of non-surgical to surgical treatment, Odds-Ratios were .98 (P = .95) for infection recurrence, and 1.05 (P = .89) for mortality. CONCLUSION Available data support that instrumented surgery can be performed safely without higher rates of infection recurrence or primary failure and lower reoperation and mortality rates compared to nonsurgical treatment for DNSI. Furthermore, spine surgical treatment may generally be performed without higher risk of infection recurrence and mortality and better quality-of-life outcomes compared to generic non-surgical treatment.
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Affiliation(s)
- Jonathan Pluemer
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
- Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Yevgeniy Freyvert
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Nathan Pratt
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Jerry E Robinson
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Jared A Cooke
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Zachary L Tataryn
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Periklis Godolias
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Zeyad A Daher
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Rod J. Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Jens R. Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
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Kim J, Oh SH, Kim SW, Kim TH. The epidemiology of concurrent infection in patients with pyogenic spine infection and its association with early mortality: A nationwide cohort study based on 10,695 patients. J Infect Public Health 2023; 16:981-988. [PMID: 37148755 DOI: 10.1016/j.jiph.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Generally, a sufficient duration of relevant antibiotics based on an appropriate culture combined with proper surgical treatment guarantees a favorable clinical outcome in patients with pyogenic spine infections. However, a patient's condition often deteriorates as concurrent infections occur in other organs, leading to mortality. Therefore, this study aimed to investigate the epidemiology of concurrent infections in patients with a pyogenic spine infection and estimate the rates and risks of early mortality. METHODS Patients with a pyogenic spine infection were identified using a national claims database that includes the entire population. The epidemiology of the six types of concurrent infections was investigated, and the corresponding early mortality rates and risks were estimated. The results were validated internally by bootstrapping and externally by defining two additional cohorts for sensitivity analysis. RESULTS Among 10,695 patients with a pyogenic spine infection, the prevalence of the six types of concurrent infections was 11.3 % for urinary tract infections, 9.4 % for intra-abdominal infections, 8.5 % for pneumonia, 4.6 % for septic arthritis or osteomyelitis of the extremities, 0.7 % for central nervous system infections, and 0.5 % for cardiac infections. Patients with a concurrent infection had approximately 4-fold greater mortality than those without (3.3 % vs. 0.8 %). The early mortality rates were particularly higher in patients with multiple or specific types of concurrent infections, including central nervous system infections, cardiac infections, and pneumonia. In addition, the mortality trends differed significantly according to the number and type of concurrent infections. CONCLUSIONS These data on six types of concurrent infection among patients with pyogenic spinal infection can be used as a source of reference by clinicians.
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Affiliation(s)
- Jihye Kim
- Division of Infection, Department of Pediatrics, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, the Republic of Korea
| | - Seung Ho Oh
- Spine Center, Department of Orthopedics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, the Republic of Korea
| | - Seok Woo Kim
- Spine Center, Department of Orthopedics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, the Republic of Korea
| | - Tae-Hwan Kim
- Spine Center, Department of Orthopedics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, the Republic of Korea.
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Herren C, von der Hoeh NH, Zwingenberger S, Sauer D, Jung N, Pieroh P, Drange S, Pumberger M, Scheyerer MJ. Spondylodiscitis in Geriatric Patients: What Are the Issues? Global Spine J 2023; 13:73S-84S. [PMID: 37084348 PMCID: PMC10177302 DOI: 10.1177/21925682221121300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
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.
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Affiliation(s)
- Christian Herren
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University, Germany
| | | | - Stefan Zwingenberger
- University Center of Orthopedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Germany
| | - Daniel Sauer
- Spinecenter, Schön Klinik Munich Harlaching University, Deutschland
| | - Norma Jung
- Department I of Internal Medicine, Medical Faculty, University Hospital of Cologne, University of Cologne, Germany
| | - Philipp Pieroh
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital Leipzig, Germany
| | - Steffen Drange
- Department of Orthopaedic Surgery, Klinikum Magdeburg gGmbH, Germany
| | - Matthias Pumberger
- Spine Department, Center for Musculoskeletal Surgery, Charité University Medicine BerlinUniversity, Germany
| | - Max J Scheyerer
- Department of Orthopedic and Trauma Surgery, Medical Faculty, University of Cologne, Germany
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Lim JS, Kim TH. Recurrence Rates and Its Associated Factors after Early Spinal Instrumentation for Pyogenic Spondylodiscitis: A Nationwide Cohort Study of 2148 Patients. J Clin Med 2022; 11:jcm11123356. [PMID: 35743427 PMCID: PMC9225581 DOI: 10.3390/jcm11123356] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 01/11/2023] Open
Abstract
Recent studies have consistently reported the safety and effectiveness of early spinal instrumentation for pyogenic spondylodiscitis. However, none of these studies investigated the recurrence rate or associated factors based on this specific group of patients. Recurrence prediction models that are not based on a homogenous cohort of patients undergoing early spinal instrumentation show theoretical limitations for clinical use. A nationwide, population-based, retrospective cohort study using a claims database was planned to investigate the recurrence rate and its associated factors in patients who underwent early instrumented spinal fusion surgery for pyogenic spondylodiscitis. We used data from the Korean National Health Insurance claims database collected between 2014 and 2018. A total of 2148 patients who underwent early (within 6 weeks after the diagnosis) instrumented spinal fusion surgery for pyogenic spondylodiscitis were included, including 1925 patients (90%) without recurrence and 223 patients (10%) with recurrence. Logistic regression models were used to identify factors associated with recurrence, and sensitivity analysis was performed according to two different definitions for recurrence: shorter (2 weeks or more) and longer (6 weeks or more) periods of antibiotic therapy for recurrence. The recurrence rates in our cohort were 14.1%, 10.4%, and 8.0% at 2, 4, and 6 weeks, respectively, in relation to the duration of antibiotic treatment for recurrence. We identified age 60−69 years (OR = 2.42), age > 70 years (OR = 2.29), posterior thoracic approach (OR = 1.85), multiple surgical approaches (OR = 4.17), use of a cage (OR = 1.66), transfusion (OR = 2.55), antibiotics for resistant organisms (OR = 2.55), and systemic steroid treatment over 2 weeks (OR = 2.27) as the factors associated with recurrence. The recurrence rates and associated factors from our first population-based and the largest clinical study can be practically used as a reasonable reference and provide clinicians with an acceptable tool for the comprehensive risk assessment for recurrence after early spinal instrumentation for pyogenic spondylodiscitis.
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Affiliation(s)
| | - Tae-Hwan Kim
- Correspondence: ; Tel.: +82-31-380-6000; Fax: +82-31-380-6008
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Clinical Characteristics of Patients with Pyogenic Vertebral Osteomyelitis and Concurrent Infections and Their Clinical Outcomes. J Pers Med 2022; 12:jpm12040541. [PMID: 35455656 PMCID: PMC9028400 DOI: 10.3390/jpm12040541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with pyogenic vertebral osteomyelitis (PVO) often develop concurrent infections, and a significant number of these patients show rapid deterioration in their medical condition, leading to mortality without PVO-related structural instability or neurological deficits. To improve clinical outcomes, we investigated the clinical presentation and treatment outcomes of patients with PVO and concurrent infections. This study included 695 patients with PVO, of which 175 (25%) had concurrent infections and 520 (75%) did not. The clinical characteristics of the two groups were compared, and multivariable analysis was performed to identify the association between concurrent infections and clinical outcomes. Patients with concurrent infections were older and had more comorbidities than those without. Moreover, there were significant intergroup differences in the anatomical involvement of PVO, and patients with concurrent infections had a higher number of regions involved more frequently than those without concurrent infections (15% vs. 6%). In contrast, patients with concurrent infections showed a lower degree of focal invasiveness, including a lower incidence of posterior abscess (47% vs. 59%; p = 0.008) and fewer neurological impairments according to the American Spinal Injury Association grade (p < 0.001) than those without concurrent infections. The causative organisms also differed significantly between the two groups, and patients with concurrent infections had a greater proportion of Gram-negative infections (31% vs. 16%, respectively) and a smaller proportion of methicillin-resistant S. aureus infections than those without concurrent infections (6% vs. 24%). Consequently, their clinical outcomes were significantly different, and patients with concurrent infections showed lower recurrence and higher mortality rates. We investigated the 1-year recurrence and mortality rates and their 95% confidence intervals according to the types of concurrent infections and their time of diagnosis and found variations in these parameters. Our results, based on a large number of patients, can be practically used as a reasonable reference to warn clinicians of the clinical risks of concurrent infections in patients with PVO and to help predict their clinical outcomes.
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