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Gonzalez GA, Porto G, Tecce E, Oghli YS, Miao J, O'Leary M, Chadid DP, Vo M, Harrop J. Advances in diagnosis and management of atypical spinal infections: A comprehensive review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100282. [PMID: 37915965 PMCID: PMC10616400 DOI: 10.1016/j.xnsj.2023.100282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/28/2023] [Accepted: 09/24/2023] [Indexed: 11/03/2023]
Abstract
Atypical spinal infections (ASIs) of the spine are a challenging pathology to management with potentially devastating morbidity and mortality. To identify patients with atypical spinal infections, it is important to recognize the often insidious clinical and radiographic presentations, in the setting of indolent and smoldering organism growth. Trending of inflammatory markers, and culturing of organisms, is essential. Once identified, the spinal infection should be treated with antibiotics and possibly various surgical interventions including decompression and possible fusion depending on spine structural integrity and stability. Early diagnosis of ASIs and immediate treatment of debilitating conditions, such as epidural abscess, correlate with fewer neurological deficits and a shorter duration of medical treatment. There have been great advances in surgical interventions and spinal fusion techniques for patients with spinal infection. Overall, ASIs remain a perplexing pathology that could be successfully treated with early diagnosis and immediate, appropriate medical, and surgical management.
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Affiliation(s)
- Glenn A. Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Guilherme Porto
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Eric Tecce
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Yazan Shamli Oghli
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Jingya Miao
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Matthew O'Leary
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | | | - Michael Vo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
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Dominguez-Cainzos J, Rodrigo-Manjon A, Rodriguez-Chinesta JM, Apodaka-Diez A, Bonmatí G, Bereciartua E. Abdominal aortic endograft infection. A decade of experience and literature review. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023; 41:155-161. [PMID: 35906173 DOI: 10.1016/j.eimce.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Aortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the "gold standar" treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy. METHODS We carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010-2019). RESULTS We describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac). CONCLUSION Perigraft or aneurysm sac aspiration culture show their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.
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Affiliation(s)
| | | | | | - Ana Apodaka-Diez
- Servicio de Medicina Interna, Hospital Universitario Cruces, Barakaldo, Spain
| | - Gonzalo Bonmatí
- Servicio de Medicina Interna, Hospital Universitario Cruces, Barakaldo, Spain
| | - Elena Bereciartua
- Servicio de Enfermedades Infecciosas, Hospital Universitario Cruces, Barakaldo, Spain.
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3
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Karczewski D, Schnake KJ, Osterhoff G, Spiegl U, Scheyerer MJ, Ullrich B, Pumberger M. Postoperative Spinal Implant Infections (PSII)-A Systematic Review: What Do We Know So Far and What is Critical About It? Global Spine J 2022; 12:1231-1246. [PMID: 34151619 PMCID: PMC9210225 DOI: 10.1177/21925682211024198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Postoperative spinal implant infections (PSII) are an increasing challenge in the daily clinical routine. This review summarizes existing knowledge in the field of PSII, including definitions, epidemiology, classifications, risk factors, pathogenesis, symptoms, diagnosis, and treatment. METHODS A systematic review was performed using a structured PubMed analysis, based on the PRISMA criteria. The search terminology was set as: "spinal implant associated infection OR spinal implant infection OR spinal instrumentation infection OR peri spinal implant infection." PubMed search was limited to the categories randomized controlled trials (RCT), clinical trials, meta-analysis and (systematic) reviews, whereas case reports were excluded. Studies from January 2000 to December 2020 were considered eligible. A total of 572 studies were identified, 82 references included for qualitative synthesis, and 19 for detailed sub analysis (12 meta-analysis, 7 prospective RCT). RESULTS Structural problems in the field of PSII were revealed, including (1) limited level of evidence in clinical studies (missing prospective RCT, metanalyzes), (2) small patient numbers, (3) missing standardized definitions, (4) heterogeneity in patient groups, and (5) redundancy in cited literature. CONCLUSION Evidence-based knowledge about spinal implant-associated infections is lacking. All involved medical fields should come together to define the term PSII and to combine their approaches toward research, training, and patient care.
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Affiliation(s)
- Daniel Karczewski
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité–Universitaetsmedizin Berlin, Berlin, Germany,Daniel Karczewski, Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Charitéplatz 1, D-10117 Berlin, Germany.
| | - Klaus J. Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany,Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Ulrich Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Max J. Scheyerer
- Department of Orthopedic and Trauma Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Bernhard Ullrich
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany,Department of Trauma and Reconstructive Surgery, BG Clinic Bergmannstrost, Halle (Saale), Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité–Universitaetsmedizin Berlin, Berlin, Germany
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Mercurio M, Sanzo V, Rava A, Galasso O, Gasparini G. Spondylodiscitis After Endovascular Aortic Repair Due to Noninvasive Listeriosis: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00113. [PMID: 34516457 DOI: 10.2106/jbjs.cc.21.00212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CASE An 83-year-old man suffered progressive lower back pain 4 weeks after an endovascular aortic repair (EVAR) procedure. Computed tomography showed L4 vertebral body collapse and abnormal soft tissue-like density swelling with increased uptake on 18F-fluoro-D-glucose (FDG) positron emission tomography (PET)/CT. Listeria monocytogenes was identified from ultrasound-guided fine-needle aspiration. Ultrasound-guided drainage of the retroperitoneal abscess and intravenous antibiotic therapy with ampicillin and gentamicin resulted in the rapid relief of symptoms. CONCLUSION Spondylodiscitis after EVAR requires a timely diagnosis. Uncommon organisms such as L. monocytogenes must be suspected, even in focal infections without signs of listeriosis. Conservative treatment with preservation of the graft should be considered as long as close follow-up evaluations are performed.
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Affiliation(s)
- Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, Mater Domini University Hospital, Catanzaro, Italy
| | - Valentina Sanzo
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, Mater Domini University Hospital, Catanzaro, Italy
| | - Alessandro Rava
- Department of Orthopedic and Traumatology, CTO Hospital, University of Turin, Turin, Italy
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, Mater Domini University Hospital, Catanzaro, Italy
| | - Giorgio Gasparini
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, Mater Domini University Hospital, Catanzaro, Italy
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Suga Y, Shigematsu H, Iida J, Sato N, Tanaka M, Kawasaki S, Yamamoto Y, Tanaka Y. Refractory Pyogenic Spondylitis Subsequent to Vascular Graft Infection: A Case Report. Spine Surg Relat Res 2021; 5:302-306. [PMID: 34435156 PMCID: PMC8356238 DOI: 10.22603/ssrr.2020-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/22/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Yuma Suga
- Department of Orthopedics and Surgery, Nara Medical University, Nara, Japan
| | - Hideki Shigematsu
- Department of Orthopedics and Surgery, Nara Medical University, Nara, Japan
| | - Jin Iida
- Department of Orthopedic Surgery, Matusaka Chuo General Hospital, Mie, Japan
| | - Nobuhisa Sato
- Department of Orthopedic Surgery, Tukazaki Hospital, Hyougo, Japan
| | - Masato Tanaka
- Department of Orthopedics and Surgery, Nara Medical University, Nara, Japan
| | - Sachiko Kawasaki
- Department of Orthopedics and Surgery, Nara Medical University, Nara, Japan
| | - Yusuke Yamamoto
- Department of Orthopedics and Surgery, Nara Medical University, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopedics and Surgery, Nara Medical University, Nara, Japan
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Dominguez-Cainzos J, Rodrigo-Manjon A, Rodriguez-Chinesta JM, Apodaka-Diez A, Bonmatí G, Bereciartua E. Abdominal aortic endograft infection. A decade of experience and literature review. Enferm Infecc Microbiol Clin 2021; 41:S0213-005X(21)00219-6. [PMID: 34452794 DOI: 10.1016/j.eimc.2021.06.018] [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: 12/13/2020] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Aortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the "gold standard" treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy. METHODS We carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010-2019). RESULTS We describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac). CONCLUSIONS Perigraft or aneurysm sac aspiration culture shows their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.
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Affiliation(s)
| | | | | | - Ana Apodaka-Diez
- Servicio de Medicina Interna, Hospital Universitario Cruces, Baracaldo, España
| | - Gonzalo Bonmatí
- Servicio de Medicina Interna, Hospital Universitario Cruces, Baracaldo, España
| | - Elena Bereciartua
- Servicio de Enfermedades Infecciosas, Hospital Universitario Cruces, Baracaldo, España.
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von der Höh NH, Pieroh P, Henkelmann J, Branzan D, Völker A, Wiersbicki D, Heyde CE. Spondylodiscitis due to transmitted mycotic aortic aneurysm or infected grafts after endovascular aortic aneurysm repair (EVAR): A retrospective single-centre experience with short-term outcomes. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:1744-1755. [PMID: 32895774 DOI: 10.1007/s00586-020-06586-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/25/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To report the challenging therapeutic approach and the clinical outcome of patients with pyogenic spondylodiscitis transmitted due to infected retroperitoneal regions of primary infected mycotic aortic aneurysms (MAAs) or secondary infected aortic stent grafts after endovascular aneurysm repair (EVAR). METHODS Between 2012 and 2019, all patients suffering from spondylodiscitis based on a transmitted infection after the EVAR procedure were retrospectively identified. Patient data were analysed regarding the time between primary and secondary EVAR infection and spondylodiscitis detection, potential source of infection, pathogens, antibiotic treatment, complications, recovery from infection, mortality, numeric rating scale (NRS), COBB angle and cage subsidence. RESULTS Fifteen patients with spondylodiscitis transmitted from primary or secondary infected aortic aneurysms after EVAR were included. The median follow-up time was 8 months (range 1-47). Surgery for spondylodiscitis was performed in 12 patients. In 9 patients, the infected graft was treated conservatively. MAAs were treated in 4 patients first with percutaneous aortic stent graft implantation followed by posterior surgery of the infected spinal region in a two-step procedure. Infection recovery was recorded in 11 patients during follow-up. The overall mortality rate was 27% (n = 4). The mean pain intensity improved from an NRS score of 8.4 (3.2-8.3) to 3.1 (1.3-6.7) at the last follow-up. CONCLUSION EVAR was used predominantly to treat primary infected MAAs. Secondary infected grafts were treated conservatively. Independent of vascular therapy, surgery of the spine led to recovery in most cases. Thus, surgery should be considered for the treatment of EVAR- and MAA-related spondylodiscitis.
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Affiliation(s)
- Nicolas Heinz von der Höh
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 18, 04103, Leipzig, Germany.
| | - Philipp Pieroh
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 18, 04103, Leipzig, Germany
| | - Jeanette Henkelmann
- Department for Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 18, 04103, Leipzig, Germany
| | - Daniela Branzan
- Department of Visceral, Transplant, Thorax and Vascular Surgery, University Hospital Leipzig, Liebigstr. 18, 04103, Leipzig, Germany
| | - Anna Völker
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 18, 04103, Leipzig, Germany
| | - Dina Wiersbicki
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 18, 04103, Leipzig, Germany
| | - Christoph-Eckhard Heyde
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 18, 04103, Leipzig, Germany
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8
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Spinal Infections: An Update. Microorganisms 2020; 8:microorganisms8040476. [PMID: 32230730 PMCID: PMC7232330 DOI: 10.3390/microorganisms8040476] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 12/13/2022] Open
Abstract
Spinal infection poses a demanding diagnostic and treatment problem for which a multidisciplinary approach with spine surgeons, radiologists, and infectious disease specialists is required. Infections are usually caused by bacterial microorganisms, although fungal infections can also occur. The most common route for spinal infection is through hematogenous spread of the microorganism from a distant infected area. Most patients with spinal infections diagnosed in early stages can be successfully managed conservatively with antibiotics, bed rest, and spinal braces. In cases of gross or pending instability, progressive neurological deficits, failure of conservative treatment, spinal abscess formation, severe symptoms indicating sepsis, and failure of previous conservative treatment, surgical treatment is required. In either case, close monitoring of the patients with spinal infection with serial neurological examinations and imaging studies is necessary.
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Sumrein HB, Parry SD, Ayer RV, Leonard AP. Infected abdominal aortic aneurysm graft complicated by lumbar discitis. BJR Case Rep 2018; 4:20170101. [PMID: 30363156 PMCID: PMC6159111 DOI: 10.1259/bjrcr.20170101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/22/2018] [Accepted: 01/25/2018] [Indexed: 11/28/2022] Open
Abstract
We present the case of a 68-year-old male, who underwent open abdominal aortic graft in August 2016 owing to a ruptured large infrarenal abdominal aneurysm. He subsequently presented 6 months later with back pain, general weakness, reduced mobility and cachexia. He underwent CT, MRI and fluorodeoxyglucose (PDG)-PET spinal imaging, all modalities showing signs of aortic graft infection complicated by L4/5 discitis. The patient was treated conservatively with intravenous antibiotics and spinal brace support, as his general condition did not allow for surgery. Although he showed initial clinical improvement allowing plans for supported discharge, his improvement was not sustained and he died 4 months after admission.
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Affiliation(s)
- Hamzeh B Sumrein
- Department of Radiology, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Sally D Parry
- Department of Gastroenterology, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Ravi V Ayer
- Department of Radiology, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Andrew P Leonard
- Department of Radiology, Poole Hospital NHS Foundation Trust, Poole, UK
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Mavrogenis AF, Megaloikonomos PD, Igoumenou VG, Panagopoulos GN, Giannitsioti E, Papadopoulos A, Papagelopoulos PJ. Spondylodiscitis revisited. EFORT Open Rev 2017; 2:447-461. [PMID: 29218230 PMCID: PMC5706057 DOI: 10.1302/2058-5241.2.160062] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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
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Affiliation(s)
- Andreas F Mavrogenis
- Attikon General University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis D Megaloikonomos
- Attikon General University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios G Igoumenou
- Attikon General University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Georgios N Panagopoulos
- Attikon General University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Efthymia Giannitsioti
- Attikon General University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Antonios Papadopoulos
- Attikon General University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis J Papagelopoulos
- Attikon General University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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