Surgical Management in Elderly Patients with Tuberculous Spondylodiscitis: Ten Year Mortality Audit Study

A clinical prediction model to differentiate tuberculous spondylodiscitis from pyogenic spontaneous spondylodiscitis

BACKGROUND

Microbiological diagnosis of tuberculous spondylodiscitis (TS) and pyogenic spontaneous spondylodiscitis (PS) is sometime difficult. This study aimed to identify the predictive factors for differentiating TS from PS using clinical characteristics, radiologic findings, and biomarkers, and to develop scoring system by using predictive factors to stratify the probability of TS.

METHODS

A retrospective single-center study. Demographics, clinical characteristics, laboratory findings and radiographic findings of patients, confirmed causative pathogens of PS or TS, were assessed for independent factors that associated with TS. The coefficients and odds ratio (OR) of the final model were estimated and used to construct the scoring scheme to identify patients with TS.

RESULTS

There were 73 patients (51.8%) with TS and 68 patients (48.2%) with PS. TS was more frequently associated with younger age, history of tuberculous infection, longer duration of symptoms, no fever, thoracic spine involvement, ≥3 vertebrae involvement, presence of paraspinal abscess in magnetic-resonance-image (MRI), well-defined thin wall abscess, anterior subligamentous abscess, and lower biomarker levels included white blood cell (WBC) counts, erythrocyte-sedimentation-rate (ESR), neutrophil fraction, and C-reactive protein (all p < 0.05). Multivariate logistic regression analysis revealed significant predictors of TS included WBC ≤9,700/mm3 (odds ratio [OR] 13.11, 95% confidence interval [CI] 4.23-40.61), neutrophil fraction ≤78% (OR 4.93, 95% CI 1.59-15.30), ESR ≤92 mm/hr (OR 4.07, 95% CI 1.24-13.36) and presence of paraspinal abscess in MRI (OR 10.25, 95% CI 3.17-33.13), with an area under the curve of 0.921. The scoring system stratified the probability of TS into three categories: low, moderate, and high with a TS prevalence of 8.1%, 29.6%, and 82.2%, respectively.

CONCLUSIONS

This prediction model incorporating WBC, neutrophil fraction counts, ESR and presence of paraspinal abscess accurately predicted the causative pathogens. The scoring scheme with combination of these biomarkers and radiologic features can be useful to differentiate TS from PS.

Prognostic values of geriatric nutrition risk index on elderly patients after spinal tuberculosis surgery

Background

Spinal tuberculosis (STB) is a significant public health concern, especially in elderly patients, due to its chronic and debilitating nature. Nutritional status is a critical factor affecting the prognosis of STB patients. The geriatric nutritional risk index (GNRI) has been established as a reliable predictor of adverse outcomes in various diseases, but its correlation with surgical outcomes in elderly STB patients has not been studied.

Objective

The study aimed to assess the prognostic value of the GNRI in elderly patients with STB who underwent surgery.

Methods

We conducted a retrospective analysis of medical records of elderly patients (65 years or older) diagnosed with active STB who underwent surgical treatment. Data collection included patient demographics, comorbidities, clinical history, laboratory testing, and surgical factors. GNRI was calculated using serum albumin levels and body weight. Postoperative complications were observed and recorded. The patients were followed up for at least 1 year, and their clinical cure status was assessed based on predefined criteria.

Results

A total of 91 patients were included in the study. We found that a GNRI value of <98.63 g/dL was a cutoff value for predicting unfavorable clinical prognosis in elderly STB patients undergoing surgery. Patients with a low GNRI had higher Charlson Comorbidity Index scores, were more likely to receive red blood cell transfusions, and had a higher prevalence of overall complications, particularly pneumonia. The unfavorable clinical prognosis group had lower GNRI scores compared to the favorable prognosis group. Multivariate analysis showed that lower GNRI independently predicted unfavorable clinical outcomes in elderly STB patients.

Conclusion

The study concluded that the GNRI is a valuable biomarker for predicting prognosis in elderly STB patients undergoing surgical intervention. Patients with lower GNRI scores had worse outcomes and a higher incidence of complications.

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.

Spontaneous spondylodiscitis: review, incidence, management, and clinical outcome in 44 patients

OBJECTIVESpontaneous spondylodiscitis remains uncommon but is a serious complication of the vertebral column. Risk factors include diabetes, hemodialysis, intravenous drug abuse, and chronic steroid use, and pain is the most common presenting symptom. This study aims to review the literature and report on the incidence, management, and clinical outcome of spontaneous spondylodiscitis in 44 patients.METHODSThis is a prospective study including 44 patients with spontaneous spondylodiscitis managed in the neurosurgery department of Cairo University Hospitals during the period between January 2012 and October 2017. All patients had a full clinical assessment, laboratory tests, radiological studies in the form of MRI with and without contrast, and a postoperative follow-up of up to 12 months.RESULTSTwelve cases underwent conservative treatment in the form of complete bed rest, intravenous antibiotics, and a spinal brace. Ten cases underwent surgical intervention in the form of laminectomy, debridement, and open biopsy. Twenty-two cases underwent laminectomy and surgical stabilization with fusion. There were 15 cases of tuberculous spondylodiscitis, 6 cases of brucellosis, 6 cases of pyogenic infection, and 17 cases in which no organism could be detected.CONCLUSIONSOnce the primary diagnosis is confirmed, early and adequately prolonged antibiotic therapy is recommended for spontaneous spondylodiscitis. Some cases can be successfully treated with conservative treatment alone, whereas surgery may be needed in other cases such as severe destruction of endplates, spinal abscess formation, mechanical instability, neurological deficits, and severe pain that have failed to respond to conservative treatment.

Role of Frailty Scoring in the Assessment of Perioperative Mortality in Surgical Management of Tuberculous Spondylodiscitis in the Elderly

STUDY DESIGN

Retrospective study.

OBJECTIVES

Treatment of spinal tuberculosis in the elderly involves consideration of compromised physiology, which often poses a clinical challenge to the surgeons to balance surgical safety versus deteriorating function. Frailty scoring has been reported as an effective tool to predict mortality and morbidity in cardiovascular surgery and recently in hip fractures. Its use in spinal surgery is scarcely reported.

METHODS

We included elderly patients operated for spinal tuberculosis. Demographic, clinical and radiological profile with operative details of instrumentation, blood loss, surgical duration and mortality were noted. Modified frailty score (MFS) was calculated for each patient. There were 26 patients (males 9, females 17) with a mean age of 73.2 years. The patients were divided into those with 30-day postoperative mortality (M) and those who survived (S). The null hypothesis was that the MFS was comparable in both the groups.

RESULTS

The M group had 5 patients (19.2%) and the S group consisted of 21 patients. There was no statistical difference between the groups with regard to mean age, sex, number of medical comorbidities, ASA (American Society of Anesthesiologists) grade, Frankel grade C or worse, blood loss, and operative time. The mean MFS in M group was 5 and in S group was 1.8, which was statistically significant (P < .001).

CONCLUSIONS

Higher MFS is associated with postoperative 30-day mortality in the elderly patients with spinal tuberculosis undergoing surgery. It can be used as a guide to predict 30-day postoperative mortality in these patients.