Vertebral Candidiasis, the State of the Art: A Systematic Literature Review

OBJECTIVE

In recent years, Candida spondylodiscitis has represented an increasingly emerging disease in clinical practice. This condition requires long-term antibiotic therapy and sometimes surgical treatments. The main purpose of this study is to investigate the epidemiology, clinical and radiological aspects, treatment protocols, and outcomes of Candida-mediated vertebral osteomyelitis.

METHODS

A systematic review of the English literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.The research was conducted on Medline, Cochrane library, PubMed, and Scopus using as search terms "vertebral"; "spinal"; "infection"; "spondylodiscitis"; "discitis"; "osteomyelitis"; "Candida"; and "Candidosis." A case of vertebral candidiasis that was surgically managed was also reported.

RESULTS

In total, 88 articles were included in our systematic review. Including the reported case, our analysis covered 113 cases of vertebral candidiasis. Candida albicans was isolated in 64 cases (56.1%), Candida tropicalis in 21 (18.4%), Candida glabrata in 14 (12.3%), and Candida parapsilosis in five (4.4%). The mean duration of the follow-up was 395 days. Finally, 87 (82%) patients completely recovered, ten (9.4%) died, and nine (8.5%) reported sequelae.

CONCLUSION

This systematic review summarized the state of the art on vertebral candidiasis, describing data on its clinical features, diagnostic criteria and current limitations, and treatment alternatives and their outcomes.

Multilevel Corpectomy for Subaxial Cervical Spondylodiscitis: Literature Review and Role of Navigation, Intraoperative Imaging and Augmented Reality

BACKGROUND

Subaxial cervical spine spondylodiscitis represents a real challenge in spine surgery. In later stages multiple spinal metamers can the interested by the pathological infection and the alteration of the spinal stability leading to spinal deformity. There is scant literature on subaxial cervical spondylodiscitis management and especially on ≥three-level cervical corpectomies. The authors conducted a literature search on this specific topic and presented an emblematic case of a patient treated with circumferential cervical fixation and four-level cervicothoracic corpectomy.

MATERIALS AND METHODS

A comprehensive literature review was performed using the combined Medical Subject Headings (MeSH) terms (multilevel) AND (sub axial spine OR cervical spine) AND (spine osteomyelitis OR spinal osteomyelitis), to search in the PubMed and Scopus databases. Our case was also included in this literature review. From our literature search the authors selected 13 papers, eight were excluded because they did not match our inclusion criteria (the involvement of only one or two levels, or did not perform corpectomy, discectomy, or cervical spine localization). The authors also presented a 71-year-old patient, in poor general clinical status who underwent several cage repositioning, with a final four-level corpectomy (C5, C6, C7, and T1), expandable C5-T1 cage positioning and C4-T2 anterior plating performed merging augmented reality, neuronavigation and intraoperative imaging.

RESULTS

This systematic review included 28 patients treated with ≥ three-level corpectomy (11 patients with three-level corpectomy, 15 patients with four-level corpectomy, and 2 patients with six-level corpectomy), 6 women, 5 men, and 17 not reported specifically, with a mean age of 55.9 years (range: 44-72 years). The combined anterior and posterior approach was taken in all but one case, which was treated with the anterior approach only. In one case of six-level cervicothoracic corpectomy, sternotomy was necessary. All reported patients recovered after surgery, except one who died after nosocomial pneumonia. No major intraoperative complications were reported. Usual postoperative complications include wound hematoma, pneumonia, subsidence, epidural hematoma, dural leakage, dysphagia, soft tissue swelling. The mean follow-up time was 31.9 months (range: 8-110 months).

CONCLUSION

According to the literature search performed by the authors, multilevel corpectomies for cervical spinal osteomyelitis is a safe and effective complex surgical procedure, even in extended procedures involving up to six levels or those at the cervicothoracic junction. The use multimodal navigation merging intraoperative imaging acquisition, navigation, and augmented reality may provide useful information during implant positioning in complex and altered anatomy and for assessing the best final result.

Autograft and allograft bone chips interbody fusion for spondylodiscitis: Surgery outcomes

Background

Spondylodiscitis is a rare illness and serious complication of the vertebral column. The suitable type of surgery is debatable for these patients. This study describes a series of cases that are treated with modified interbody fusion for the treatment of spondylodiscitis by combining allograft and autograft bone chips with posterior segmental fusion.

Methods

This was a retrospective study. The clinical deficit was evaluated with ASIA, VAS, and JOABPEQ scores before and after surgery. Radiological parameters were assessed with local kyphosis angle (degree), segmental height correction, and loss of correction. Post-operative bone union was evaluated as suggested by Tan et al.

Results

The mean age of patients (n=34) was 52.3(SD=13.6) years and 67.6% were males. The mean follow-up duration was 25.8 (2.3) months. In the last follow-up, VAS back pain 4.9(0.77), VAS leg pain 4.6(0.78), JOABPEQ low back pain 68.1 (9.3), JOABPEQ lumbar function 81.3 (8.9), and JOABPEQ walking ability 72.8 (8.3) shows a significant difference when compared with preoperative scores. According to ASIA grading, none of the patients deteriorated neurologically (all p<0.0001). The average segmental height correction and loss of correction were observed 7.5(3.7) % and -1.8(3.6) %, respectively, indicating improvements in the patients. A high union fusion rate (82.4%) was observed in the last follow-up.

Conclusion

This modified method can be a safe and effective technique for surgical intervention in patients with spondylodiscitis.

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.

Spinal infection with intraspinal abscess or empyema and acute myelopathy: comparative analysis of diagnostics, therapy, complications and outcome in primary care

INTRODUCTION

This study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account.

METHODS

Patients were enrolled in an ambispective study (2012-2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan-Meier method and Cox regression.

RESULTS

In total, 134 patients with a median (IQR) age of 72 (61-79) years were analyzed. Baseline characteristics were similar between the SCI (n = 55) and noSCI (n = 79). A higher percentage of endocarditis (9% vs. 0%; p = 0.03) was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group (e.g., urinary tract infection, pressure ulcers). Lethality risk factors were age (HR 1.09, 95% CI 1.02-1.16, p = 0.014), and empyema/abscess extension (≥ 3 infected spinal segments, HR 4.72, 95% CI 1.57-14.20, p = 0.006), dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%.

CONCLUSION

PSI + are associated with higher in-hospital mortality, particularly when multiple spinal segments are involved. However, survival is similar with (SCI) or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates.

Spontaneous spondylodiscitis and epidural abscess due to Listeria monocytogenes in a middle-aged patient with gentamicin related side effects: A case report and a review of literature

Introduction

Primary spondylodiscitis due to Listeria monocytogenes (LM) is a rare condition.

Research question

We present a case of spontaneous LM spondylodiscitis with an epidural abscess in a middle-aged man, who reported no gastrointestinal infection.

Material and methods

We identified 5 spinal infection cases due to LM in the literature, with 3 diagnosed as primary spondylodiscitis.

Results

The patient was treated with surgical decompression, debridement, and antibiotic therapy. Blood cultures remained negative throughout the case and microbiological cultures were obtained during surgery. The patient developed side-effects of prolonged gentamicin therapy but made a recovery from his spinal complaints at 6-months follow-up. Listeriosis is a relatively rare food-borne disease with a wide spectrum of presentation. Surgeons should consider more aggressive therapy for spinal infections and recognize the uncommon manifestations. We identified 3 primary and 2 secondary LM spondylodiscitis cases in the literature. Antibacterial treatment of LM spondylodiscitis varied in agents and duration, but no side-effects were previously reported. Gentamicin treatment requires care and attention to complications.

Discussion and conclusion

Listeria monocytogenes is a rare cause of primary spondylodiscitis. Further studies are needed to establish a safe treatment protocol for treatment with gentamicin and LM spondylodiscitis.

Infective spondylodiscitis in hemodialysis patients

Background

Spondylodiscitis is a potentially catastrophic complication in patients on hemodialysis. It is slow and insidious onset and nonspecific symptoms have contributed to the late detection of this infectious process. Here, we reviewed the clinical characteristics and outcomes for patients on hemodialysis who developed spondylodiscitis who were diagnosed with spondylodiscitis.

Methods

From 2011 to 2021, 11 (0.4%) of 2557 patients on hemodialysis were diagnosed with spondylodiscitis based on clinical symptoms, patients averaged 56.9 years of age, seven were male, and they presented with fever in just two cases. The most frequent comorbidities included hypertension (ten patients) and diabetes mellitus (seven patients). Here, we reviewed the clinical, radiological (i.e., MR scans), laboratory markers, and treatment choices (i.e., nonsurgical vs. surgical) for these 11 hemodialysis patients.

Results

Ten of the 11 patients underwent spinal surgery, and five were later readmitted for recurrent of infections. There was just one nonsurgical mortality.

Conclusion

For patients on hemodialysis, the new-onset of spinal pain may signal the onset of spondylodiscitis which should be rapidly diagnosed with MR studies and managed in a timely fashion either with antibiotic therapy and/or with surgery/antibiotics.

Stress With Bubbles: Echocardiographic Visualization of a Typical Pathway Between the Spine and the Heart

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Right atrial bubbles were detected without active infusion during stress echocardiography.

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Bubbles can be caused by the VP.

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The VP occurs as a result of degeneration of intervertebral disks.

Noncontiguous multifocal Brucella spondylodiscitis with paravertebral abscess: a case report

Background

Human brucellosis is the most frequently contracted zoonotic infection worldwide. Although being an old disease that carries minimal risks of mortality, it remains a source of considerable sequelae and disability. However, noncontiguous multifocal spinal involvement is an exceptional presentation of brucellosis; additionally, an associated paravertebral abscess is extremely rare.

Case presentation

This paper focuses on a 67-year-old Lebanese woman with noncontiguous multifocal Brucella spondylodiscitis, involving the T12–L1 and L3–L4 segments, with paravertebral abscess formation. She presented with a 3-week history of acute severe lumbar back pain, radiating to the lower extremities and associated with impaired mobility and lower extremity weakness. The patient complained of night sweating but had no fever. No lymphadenopathy, hepatomegaly, or splenomegaly could be observed. She had painful percussion of the lumbar spine, painful passive mobilization, and paravertebral tenderness, yet her neurological examination was completely normal. BrucellaCapt test was positive at a titer of 1/5120 (reference range 1/180). The patient was treated with an inpatient regimen for 2 weeks, which was followed by an outpatient oral antibiotic regimen with doxycycline, rifampin, and ciprofloxacin to complete a total treatment duration of 3 months. Magnetic resonance imaging was performed at the end of the treatment and showed a complete resolution of the paravertebral abscess.

Conclusion

Noncontiguous multifocal Brucella spondylodiscitis with paravertebral abscess is an extremely rare presentation. It may be effectively managed by antibiotic therapy, without surgery or drainage, in the absence of neurological complications. Nonetheless, the principal challenge to an efficient management is establishing the diagnosis of Brucella in the first place. In endemic countries, a strong suspicion of spinal involvement of brucellosis should be elicited in front of back pain presentations—even in the absence of fever and other related symptoms.

Treatment of Refractory Multilevel Thoracic Spondylodiscitis Using Ultra-Minimally Invasive Endoscopic Approach for Debridement and Drainage: A Technical Note, Intraoperative Video, and Literature Review

OBJECTIVE/BACKGROUND

Spondylodiscitis is an infection of the spinal column which can result in pain, deformity, instability, and/or neurologic deficits. When surgical treatment is required for thoracic spondylodiscitis, invasive open approaches are often utilized due to the ventral location of the pathology.

METHODS

We describe the use of a spinal endoscope to perform drainage and debridement of infected tissue through a transforaminal/intradiscal approach in a patient with multilevel thoracic spondylodiscitis refractory to antibiotic therapy. Illustrative videos are provided, as well as a review of the relevant literature.

RESULTS

A total of 188 patients were included in the systematic review. The mean positive reported culture rate was 76% (117/154 patients). The mean preoperative visual analog scale score was 6.8 (n = 114), and the mean postoperative visual analog scale score was 1.8 at 1 week postoperatively (n = 56) and 1.01 at the final follow-up (n = 114). The most common surgical approach was transforaminal/intradiscal (103/188 patients, 54.8%). The mean reoperation rate was 9.1%. The mean complication rate was 5.25%, with complications including increased transient radicular pain, infection, hardware failure, and new unspecified neurological deficits.

CONCLUSION

This case and those highlighted in our literature review demonstrate that endoscopic treatment for thoracic spondylodiscitis is a viable alternative to traditional open surgery in many cases.

An Uncommon Case of Brucellar Spondylodiscitis: A Case Report

Introduction

Infective spondylodiscitis refers to simultaneous inflammation of vertebrae and disc and usually occurs through hematogenous spread. The most common presentation of brucellosis is febrile illness, but it can rarely present as spondylodiscitis. Rarely, human cases of brucellosis are diagnosed and treated clinically. We describe a case of previously healthy man in his early 70s who presented with symptoms suggestive of spinal tuberculosis, then diagnosed to have brucellarspondylodiscitis.

Case Report

A 72-year-old farmer presented to our orthopedic department with a history of chronic lower back pain. Spinal tuberculosis was suspected at a medical facilitynear his residence, based on magnetic resonance imaging consistent with infective spondylodiscitis, and the patient was referred to our hospital for further management. Investigations revealed that the patient had an uncommon diagnosis of Brucellar spondylodiscitis for which he was managed accordingly.

Conclusion

Brucellar spondylodiscitis may clinically mimic spinal tuberculosis; hence, it must be considered as a differential diagnosis in a patient presenting with the lower back pain (particularly in the elderly) and signs of a chronic infection. Screening serological testing is vital in early identification and management of spinal brucellosis.

Infectious hematogenous lumbar spondylodiscitis caused by Actinotignum schaalii in a 74-year-old man: A case report

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Haematogenous bacterial spondylodiscitis due to infection with a well-treatable but easily overlooked and often underdiagnosed pathogen.

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An argument against short pedicle screw instrumentation, when urgent surgical therapy of the infected spine is required, in patients with PD and poor general condition.

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Especially in cases where a bacterial infection is suspected clinically and by imaging, the detection of germs must be forced by all means in order to be able to treat the patients well.

Steady-state concentrations of flucloxacillin in porcine vertebral cancellous bone and intervertebral disc following oral and intravenous administration assessed by microdialysis

AIMS

Flucloxacillin is a frequently used antibiotic in the treatment of spondylodiscitis. We assessed steady-state concentrations and time above minimal inhibitory concentration (fT > MIC) of flucloxacillin in the intervertebral disc, vertebral cancellous bone, subcutaneous tissue and plasma, after intravenous and oral administration.

METHODS

Sixteen pigs were randomized into two groups; Group Peroral (Group PO) and Group Intravenous (Group IV) received 1 g flucloxacillin every 6 h for 24 h orally or intravenously. Microdialysis was used for sampling in the compartments of interest. A flucloxacillin target of 50% fT > MIC was applied for three MIC targets: 0.125, 0.5 and 2.0 μg/mL.

RESULTS

Intravenous administration resulted in significantly longer fT > MIC for all targets. Target attainment was only reached for the low target of 0.125 μg/mL in Group IV in vertebral cancellous bone, subcutaneous tissue, and plasma (intervertebral disc 47%). In Group IV, mean fT > MIC values in the investigated compartments were in the range of 47-67% of the dosing interval for 0.125 μg/mL, 20-35% for 0.5 μg/mL, and 0-15% for 2.0 μg/mL. In Group PO, mean fT > MIC values for 0.125 μg/mL were in the range of 1-33%. No pigs reached a concentration of 0.5 μg/mL in any of the investigated compartments in Group PO.

CONCLUSION

Administration of 1 g flucloxacillin every 6 h resulted in surprisingly low steady-state fT > MIC after intravenous and oral administration. However, intravenous administration resulted in significantly higher concentrations across compartments compared to oral administration. Sufficient target tissue concentrations for treatment of spondylodiscitis may require a dose increase or alternative dosing regimens.

Total en bloc spondylectomy in the treatment of postoperative chronic osteomyelitis: a case report

BACKGROUND

Infection of the spine after surgical procedures is one of the most dreaded complications of spinal fusion surgery. Treatment goals are to eradicate the necrotic and infected tissue and to obtain a correct spinal profile. Traditionally many authors have recommended the posterolateral or double approach, anterior and posterior. Total en bloc spondylectomy is a surgical procedure traditionally used to treat primary and metastatic tumors. The use of this surgical procedure in treatment of chronic vertebral osteomyelitis is not clearly defined in literature.

CASE DESCRIPTION

This case involved a 66-year-old female patient with a history of T9-S1 instrumentation after several surgeries, who developed chronic osteomyelitis of T8-T9 with extensive destruction of the vertebral body and severe thoracic kyphosis. After targeted antibiotic therapy, total en bloc spondylectomy of T8-T9 was performed according to the Tomita technique. Necrotic and infected tissues were removed proceeding as if it were chronic osteomyelitis of long bones and performing en bloc resection with clear margins, that is, applying the criteria of oncological surgery to this chronic infection. After resection, the sagittal plane is reconstructed in the affected segment, restoring the normal distance between the two healthy vertebrae and the mechanical stability of the spine.

CONCLUSIONS

Total en bloc spondylectomy in the treatment of extensive infectious lesions with a mechanical component allows performing en bloc resection of infected and necrotic tissue along with biological and mechanical reconstruction. In our case, the complete resection of the infected bone and soft tissues achieved good outcome without complications. We propose total en bloc spondylectomy as a reasonable treatment option in complicated spondylodiscitis progressing to extensive chronic osteomyelitis and compromising spinal stability due to a significant loss of bone material.

Vaginal microbiota as an unusual cause of spondylodiscitis

The incidence of extra pelvic infections due to vaginal microflora bacteria has increased as growth media and methods of isolation have improved. However, bone infections seem to be still relatively rare, and little is known about their risk factors, clinical presentation, treatment and final outcome. We describe here a spondylodiscitis due to Gardnerella vaginalis, Atopobium vaginae, Peptostreptococcus indolicus and Prevotella amnii, anaerobic bacteria from vaginal microbiota. Our patient had no obvious predisposing factor and recovered after antibiotic treatment. To our knowledge, this case is the first reported spondylodiscitis caused by polymicrobial vaginal flora in a healthy, immunocompetent woman.

Minimally invasive outpatient management of iliopsoas muscle abscess in complicated spondylodiscitis

BACKGROUND

Iliopsoas muscle abscess (IPA) and spondylodiscitis are two clinical conditions often related to atypical presentation and challenging management. They are both frequently related to underlying conditions, such as immunosuppression, and in many cases they are combined. IPA can be primary due to the hematogenous spread of a microorganism to the muscle or secondary from a direct expansion of an inflammatory process, including spondylodiscitis. Computed tomography-guided percutaneous drainage has been established in the current management of this condition.

AIM

To present a retrospective analysis of a series of 8 immunocompromised patients suffering from spondylodiscitis complicated with IPA and treated with percutaneous computed tomography-guided drainage and drain insertion in an outpatient setting.

METHODS

Patient demographics, clinical presentation, underlying conditions, isolated microorganisms, antibiotic regimes used, abscess size, days until the withdrawal of the catheter, and final treatment outcomes were recorded and analyzed.

RESULTS

All patients presented with night back pain and local stiffness with no fever. The laboratory tests revealed elevated inflammatory markers. Radiological findings of spondylodiscitis with unilateral or bilateral IPA were present in all cases. Staphylococcus aureus was isolated in 3 patients and Mycobacterium tuberculosis in 2 patients. Negative cultures were found in the remaining 3 patients. The treatment protocol included percutaneous computed tomography-guided abscess drainage and drain insertion along with a course of targeted or empiric antibiotic therapy. All procedures were done in an outpatient setting with no need for patient hospitalization.

CONCLUSION

The minimally invasive outpatient management of IPA is a safe and effective approach with a high success rate and low morbidity.

Diagnostic Yield of Computed Tomography-Guided Procedures for Spondylodiscitis

PURPOSE

To identify the diagnostic yield and predictive factors for microbiological diagnosis in patients with spondylodiscitis through computed tomography (CT)-guided biopsy or aspiration.

MATERIALS AND METHODS

A retrospective review of 102 patients with suspected spondylodiscitis who underwent CT-guided procedures in an 8-year period was conducted. Analyzed variables were demographic data, C-reactive protein, pre-biopsy MRI findings, prior antibiotic use, site of biopsy/aspiration, histopathological findings, culture results and radiation dose.

RESULTS

The culture yield among all sites was 56%, 85.6% for paravertebral/discal fluid aspiration, 66.7% for disk-only biopsy, 52.9% for paravertebral soft tissue biopsy, and 39.6% for endplate bone-disk unit. Patients with paravertebral/disk collection on MRI had better yields when submitted to fluid aspiration instead of biopsy of other sites (78.9% vs. 36.6%; p = 0,006). Pyogenic etiology corresponded to 68.3% of cases and Staphylococcus aureus was the most common agent. Prior antibiotics exposure was associated with a lower yield (66.2% vs. 40.9%, p = 0,016).

CONCLUSIONS

CT-guided procedures are safe and well-tolerated in patients with suspected spondylodiscitis, with good microbiologic yield particularly in the presence of paravertebral/discal abscess.

[An abdominal mass of unexpected etiology]

Concomitant existence of spondylodiscitis and a psoas abscess in a patient with a history of plasmacytoma should be the subject of extensive etiological research.

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.

A follow-up case of relapsing tuberculous spondylodiscitis, complicated with soft-tissues abscess and percutaneous fistula

Spinal tuberculosis (Pott's disease) is a frequent manifestation of Mycobacterium tuberculosis infection. It manifests as destruction of 2 or more adjacent vertebral bodies followed with destruction of the intervertebral disc, leading to a condition known as spondylodiscitis. Tuberculous spondylodiscitis represents with back pain, fever, joint stiffness, loss of spinal mobility, neurological symptoms, vertebral body collapse, gibbus formation and kyphosis. Persistent Pott's disease might lead to soft tissues abscesses, frequently involving iliopsoas muscle. We, herein, present a 20 years long follow-up case of a Pott's disease patient. The patient got diagnosed as tuberculous spondylodiscitis, almost 10 years after first symptoms onset. She underwent frequent computed tomography and magnetic resonance scanning, with spinal spondylodiscitis being its only significant finding, while lung parenchyma and other organs were not infected. Patient got treated with multidrug anti-tubercular regimen for 18 months in 2 different periods of time; nonetheless she complicated with iliopsoas muscle abscess and percutaneous fistula. Early diagnosis and treatment of spinal tuberculosis (TB) are of great importance in ensuring a good clinical outcome. Delaying the diagnosis and proper management can lead to spinal cord compression, deformity and irreversible neurological complications. Thus, multidrug anti-tubercular therapy must be started timely and the duration of anti-tubercular therapy needs to be individualized. The decision to terminate anti-tubercular therapy should be based on clinical, radiological, pathological and microbiological indices, rather than being based on specific guidelines.

Thoracic spondylodiscitis secondary to Klebsiella oxytoca urosepsis-a case report

Spondylodiscitis is an insidious and infectious pathology of the spinal column attributable to pathogenic micro-organisms and occurs in a variety of contexts. These micro-organisms can be inoculated surgically or can metastasise from distant sites of infection. Klebsiella species are important community-acquired and nosocomial pathogens but are uncommonly implicated in spinal infection. Klebsiella oxytoca is more obscure than its generic relative Klebsiella pneumoniae and has only five times previously been reported in spondylodiscitis. It possesses the ability to acquire inducible and recombinant antibiotic resistance, especially in the hospital setting. We describe the case of an elderly man with complex urology and this rare sequela due to incomplete treatment of a K. oxytoca urinary infection. He developed sepsis that recurred after incomplete antibiosis and seeded to his thoracic spine causing overt spondylodiscitis. The infection fulminated and his spinal lesion deteriorated into acute spinal cord compression with neurological compromise, requiring surgical decompression, fixation and long-term antibiotics. This is a sixth documented instance of a rare spinal bacterial infection. We describe the relevant microbiology and pathology, neurosurgical considerations, and general practice points for clinicians. Our report is a novel illustration of the potentially catastrophic consequences of inadequately treated urosepsis and is a stark reminder of the importance of antimicrobial stewardship.

Endoscopic treatment of spondylodiscitis: systematic review

BACKGROUND

Spondylodiscitis is a severe condition where standalone antibiotic therapy resolves most cases. In refractory infections, open surgery may aid with infection debulking. However, significant morbidity can occur. Nowadays, endoscopic approaches are emerging as an alternative. However, until now, only small-scale studies exist. Being so, we carried the first systematic review on spondylodiscitis endoscopic debridement indications, technique details, and outcomes.

METHODS

Search for all English written original studies approaching the spondylodiscitis endoscopic treatment was performed using PubMed and EBSCO host. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a pre-specified protocol was registered at PROSPERO (CRD42020183657).

RESULTS

Fourteen studies involving 342 participants were included for analysis. Data overall quality was fair. Indications for the endoscopic approach were poorly defined. The most consensual indication was refractory infection to conservative treatment. Spinal instability or neurological deficits were common exclusion criteria. All authors described similar techniques, and despite the frequent severe co-morbidities, procedure morbidity was low. Re-interventions were common. Microorganism identification varied from 54.2 to 90.4%. Treatment failure among studies ranged from 0 to 33%. Pain, functional status, and neurological deficits had satisfactory improvement after procedures.

CONCLUSIONS

The endoscopic debridement of spondylodiscitis seems to be an effective and safe approach for refractory spondylodiscitis. A novel approach with initial endoscopic infection debulking and antibiotic therapy could improve the success of spondylodiscitis treatment.

Streptococcus suis spondylodiscitis: 2 new cases and a literature review

INTRODUCTION

Streptococcus suis (S. suis) infection is poorly described zoonosis in our country, which is related with exposure to pigs or their meat. The most common clinical presentation is meningitis, while spine's involvement is rare.

METHODS

We report 2 cases of S. suis infection and perform a systematic review of the articles published on S. suis spondylodiscitis between January 1994 and May 2020 with the aim of defining the clinical characteristics, predisposing factors and evolution.

RESULTS

17 cases are described, 76.5% males with a mean age of 57.6 years, generally without associated underlying disease. Enolism was a factor present in 17.6%. 70.6% had exposure to pigs or their meat and 20% hand injuries. The mean duration of symptoms was 10.2 days and the most affected segment was the lumbar level. 70.6% had meningitis. All were treated with beta-lactams with an average duration of 53.2 days. There was a recurrence and none died.

CONCLUSION

There are few cases of S. suis spondylodiscitis in the literature. When occurs, it is associated with another type of infection in most cases. They present a good response to medical treatment and a good prognosis.

An inter- and intra-rater agreement assessment of a novel classification of pyogenic spinal infections

PURPOSE

Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification.

METHODS

Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (wκ) to establish the inter- and intra-observer agreement.

RESULTS

The inter-observer agreement was substantial considering the main categories (wκ = 0.77; 0.71-0.82), but moderate considering the subtypes (wκ = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (wκ = 0.65; 0.59-0.71), and moderate considering the subtypes (wκ = 0.58; 0.54-0.63).

CONCLUSION

The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate.

Severity and Outcome of Neurologic Deficits in Patients with Pyogenic Spondylodiscitis: A Systematic Review

Patients with advanced pyogenic spondylodiscitis can present with neurologic deficits. However, the prevalence, severity, and outcome of the neurologic deficits are not well known. A systematic review was performed to improve the knowledge of this commonly encountered clinical scenario. The considerable number of severe neurologic deficits in addition to their poor recovery, even after surgical intervention, demonstrates that the early diagnosis of pyogenic spondylodiscitis is crucial. Prompt surgical intervention is likely associated with a greater chance of improvement of neurologic status than nonsurgical treatment.