Operative treatment of spondylodiscitis--what is the most effective approach?

Quality of Life Following Surgical and Conservative Therapy of Pyogenic Spinal Infection: A Study of Long-term Outcome in 210 Patients

OBJECT

 The management and recommendations for treatment strategies of pyogenic spinal infection are still a highly controversial issue. The purpose of this study was to evaluate patient's quality of life (QoL) after surgical and conservative treatment of spinal infection.

MATERIALS AND METHODS

 We conducted a retrospective, single-center study. All patients treated between 2009 and 2016 were included in this study. For evaluation of QoL, we recorded each patient's satisfaction according to the 36-Item Short Form Health Survey (SF-36) questionnaire. Scores were compared with a U.S. standard population.

RESULTS

 Two hundred and ten adult patients with spondylodiskitis were identified. Of these, 155 (74%) underwent surgery and 55 (26%) were treated conservatively. The mean overall age was 68.6 (23-98) years. Seventy-two patients were females and 138 patients were males. The mean outcome values in the surgical group did not reach the level of the normative sample in one of eight items, whereas the conservative group revealed a reduced QoL in all items. Intergroup comparison revealed significant differences in all items (p < 0.05).

CONCLUSION

 In the patient population we investigated, QoL in surgically treated patients was better than that in conservatively managed patients.

Spondylodiscitis: experience of surgical management of complicated cases after failed antibiotic treatment

INTRODUCTION

The term Spondylodiscitis (SD) involves infection of the vertebra (Spondylitis), infection of the intervertebral disc (Discitis), or both (Spondylodiscitis). SD represents a diagnostic and therapeutic challenge to any spine surgeon. Any delay in its diagnosis or management may cause serious long-term morbidity or even lead to mortality. In this study, we report the experience of our Institution in the management of severe and complicated cases of SD.

METHODS

Over a period of 1 year, 39 patients with the diagnosis of SD were surgically treated in Assiut University Hospital, Assiut, Egypt. The management processes were tailored according to the clinical condition, radiological and lab studies of each case; and patients were then prospectively followed-up until they were cured (for a minimum of 6 months). The outcomes were analyzed, to be able to give recommendations while aiming to improve the overall outcome of such dangerous health issue.

RESULTS

In this series, patients were managed surgically by drainage and debridement of the infection site with/without instrumented fusion. Results included: satisfactory fusion was achieved in 97.3% of patients (confidence interval [CI] = 0.6856-1.3421). Neurological Improvement Rate (NIR) was 71.5% (Statistically significant improvement P-value = 0.014) and reoperation rate was 5% (CI = 0.00621-0.18525). Mortality rate was 7.7% (CI = 0.016-0.209). Several aspects were analyzed in each case.

CONCLUSION

Surgical management of severe and complicated cases of SD allows for effective debridement and rapid cure of inflammation, earlier patient mobilization and significantly shorter duration of antibiotic usage.

Operative Management of Spinal Infection Among Intravenous Drug Abusers

OBJECTIVE

Recent population-level increases in intravenous drug abuse (IVDA) may contribute to incidence of spinal infection. The aim of this study was to evaluate national trends of spinal infections and evaluate effect of IVDA on outcomes in operative management of spinal infection.

METHODS

Using the National (Nationwide) Inpatient Sample database for 2002-2014, all patients undergoing spinal decompression or fusion for treatment of spinal infection were evaluated. Inpatient outcomes included length of stay, total cost, complications, discharge to facility, reoperations, and inpatient mortality. Bivariate and multivariate logistic regression analyses were performed to compare patients with IVDA and patients without IVDA.

RESULTS

A total of 60,964 patients undergoing surgical management of spinal infection were identified. Number of surgically managed spine infections increased from 2002 to 2014 (P < 0.0001). Proportion of surgically managed spine infections associated with IVDA increased from 3.3% in 2002 to 14.0% in 2014 (P < 0.0001). IVDA was associated with increased hospital length of stay (odds ratio = 1.38; 95% confidence interval, 1.32-1.45; P < 0.0001) and greater total charges (odds ratio = 1.23; 95% confidence interval, 1.17-1.29; P < 0.0001). No other significant differences between groups were noted.

CONCLUSIONS

From 2002 to 2014 in the United States, the incidence of operatively treated spine infections increased 227.9%, and the proportion of cases associated with IVDA significantly increased. Patients with IVDA had a longer mean length of stay and increased inpatient cost of care but were not at increased risk for complication, reoperation, or mortality. These findings are important for surgeons, internists, hospitals, and insurers to ensure proper resource allocation in treating these at-risk patients.

Presentation and Outcomes After Medical and Surgical Treatment Versus Medical Treatment Alone of Spontaneous Infectious Spondylodiscitis: A Systematic Literature Review and Meta-Analysis

STUDY DESIGN

Systematic literature review.

OBJECTIVES

The aims of this study were to (1) describe the clinical features, disabilities, and incidence of neurologic deficits of pyogenic spondylodiscitis prior to treatment and (2) compare the functional outcomes between patients who underwent medical treatment alone or in combination with surgery for pyogenic spondylodiscitis.

METHODS

A systematic literature review was performed using PubMed according to PRISMA guidelines. No year restriction was put in place. Statistical analysis of pooled data, when documented in the original report (ie, number of patients with desired variable and number of patients evaluated), was conducted to determine the most common presenting symptoms, incidence of pre- and postoperative neurologic deficits, associated comorbidities, infectious pathogens, approach for surgery when performed, and duration of hospitalization. Outcomes data, including return to work status, resolution of back pain, and functional recovery were also pooled among all studies and surgery-specific studies alone. Meta-analysis of studies with subgroup analysis of pain-free outcome in surgical and medical patients was performed.

RESULTS

Fifty of 1286 studies were included, comprising 4173 patients undergoing either medical treatment alone or in combination with surgery. Back pain was the most common presenting symptom, reported in 91% of patients. Neurologic deficit was noted in 31% of patients. Staphylococcus aureus was the most commonly reported pathogen, seen in 35% of reported cases. Decompression and fusion was the most commonly reported surgical procedure, performed in 80% of the surgically treated patients. Combined anterior-posterior procedures and staged surgeries were performed in 33% and 26% of surgeries, respectively. The meta-analysis comparing visual analog scale score at follow-up was superior among patients receiving surgery over medical treatment alone (mean difference -0.61, CI -0.90 to -0.25), while meta-analysis comparing freedom from pain in patients receiving medical treatment alone versus combined medical and surgical treatment demonstrated superior pain-free outcomes among surgical series (odds ratio 5.35, CI 2.27-12.60, P < .001), but was subject to heterogeneity among studies (I ² = 56%, P = .13). Among all patients, freedom from pain was achieved in 79% of patients, and an excellent outcome was achieved in 73% of patients.

CONCLUSION

Medical management remains first-line treatment of infectious pyogenic spondylodiscitis. Surgery may be indicated for progressive pain, persistent infection on imaging, deformity or neurologic deficits. If surgery is required, reported literature shows potential for significant pain reduction, improved neurologic function and a high number of patients returning to a normal functional/work status.

Spontaneous Pyogenic Spondylodiscitis in the Thoracic or Lumbar Spine: A Retrospective Cohort Study Comparing the Safety and Efficacy of Minimally Invasive and Open Surgery Over a Nine-Year Period

PURPOSE

Pyogenic spondylodiscitis is a rare disease, but its incidence is increasing. Over the last decade, spinal surgery has been modified to become minimally invasive. In degenerative spinal disorders, such minimally invasive surgery (MIS) reduces blood loss, muscular trauma, and the hospital stay. However, it is not known whether MIS also confers these benefits to patients with pyogenic spondylodiscitis. This retrospective cohort study compared the safety and efficacy of MIS and the conventional open surgical procedure in patients with pyogenic spondylodiscitis.

METHODS

The study cohort consisted of all consecutive patients who underwent surgery for thoracic or lumbar pyogenic spondylodiscitis that was not caused by previous surgery or tuberculosis in our tertiary-care institution between January 2003 and December 2011.

RESULTS

Of the 148 eligible patients, 75 and 73 underwent MIS and open surgery, respectively. The 2 groups did not differ in terms of age, body mass index, American Society of Anaesthesiologists score, comorbidities, septic disease, or preoperative neurologic deficit. The 2 methods were associated with similar postoperative stays in the intensive care unit, overall hospital stays, complication rates, and postoperative survival. However, MIS was associated with a significantly shorter operating time, a lower perioperative need for blood products, and, as expected, an increased intraoperative fluoroscopy duration.

CONCLUSIONS

Our 9-year experience suggests that MIS is safe and effective for spontaneous pyogenic thoracic and lumbar spondylodiscitis.

A retrospective study of 113 consecutive cases of surgically treated spondylodiscitis patients. A single-center experience

BACKGROUND

Recommendations for the operative treatment of spondylodiscitis are still a controversial issue.

METHODS

A retrospective review identified 113 consecutive patients who underwent surgical debridement and instrumentation for spondylodiscitis between 2006 and 2010 at our department.

RESULTS

The mean age at presentation was 65 years; 78 patients were male (69 %). Distribution of the inflammation was lumbar in 68 (60 %), thoracic in 19 (17 %) and cervical in 20 (18 %) cases. Six patients (5 %) had two concomitant non-contiguous spondylodiscitis foci in different segments of the spine. Epidural abscess was found in 33 patients (29 %). One hundred four patients (92 %) had pain. Neurological deficit was found in 40 patients (35 %). In the thoracic and lumbar cases, dorsal instrumentation alone was considered sufficient in 26 cases; additional interbody fusion from the posterior was performed in 44 cases. A 360° instrumentation was performed in 22 cases. In the cervical cases, only ventral spondylodesis and plating were performed in eight cases, only dorsal instrumentation in five and 360° instrumentation in seven. Postoperative intravenous antibiotics were administered for 14.4 ± 9.3 (mean ± SD) days followed by 3.2 ± 0.8 (mean ± SD) months of oral antibiosis. Complete healing of the inflammation was achieved in 111 (98 %) cases. Two patients died because of septic shock, both with fulminant endocarditis. Pain resolved in all cases. Neurological deficits were completely resolved in 20 patients, and 14 patients had a partial recovery.

CONCLUSION

The results of our retrospective study show that surgical treatment of spondylodiscitis with a staged surgical approach (if needed) and a short 1-2-week period of intravenous antibiotics followed by 3 months of oral antibiotics is appropriate for most patients in whom conservative treatment has failed or is not advisable. Furthermore, surgical treatment of newly diagnosed spondylodiscitis might be recommended as an initial treatment option in many cases. Thereby the choice of fusion material (autologous bone, titanium, PEEK) seems less important.

Posterior interbody grafting and instrumentation for spondylodiscitis

PURPOSE

To report outcomes of 7 patients with bacterial spondylodiscitis treated through a posterior approach.

METHODS

Five men and 2 women aged 40 to 80 years underwent one-stage posterior interbody debridement and instrumentation for single-segment bacterial spondylodiscitis of lumbar (n=5) or thoracic (n=2) vertebrae. The Oswestry Disability Score, the Frankel classification, the Cobb angle, and the visual analogue scale (VAS) for pain as well as bone union on radiographs were assessed.

RESULTS

Patients were followed up for 19 to 36 months. None had relapses or complications. Postoperatively, 5 patients had no pain or used analgesics only occasionally; their VAS scores varied from 0 to 20. The remaining 2 patients had residual symptoms and received regular peripheral pain medication and opiates; their VAS scores ranged from 30 to 50. The mean Oswestry Disability Score improved to 21 (range, 12-38). The mean Cobb angle improved from 13.1 to 11.1 degrees. The segments were probably fused in 5 patients and questionable in 2.

CONCLUSION

Posterior debridement and instrumentation was adequate for single-segment spondylodiscitis and achieved good outcomes.

Two recurrences of adjacent spondylodiscitis after initial surgical intervention with posterior stabilization, debridement, and reconstruction of the anterior column in a patient with spondylodiscitis: a case report

STUDY DESIGN

Case report.

SUMMARY OF BACKGROUND DATA

This report describes a patient who had 2 episodes of destructive spondylodiscitis occurring adjacent to levels at which surgery had previously been carried out due to an initial spondylodiscitis. A review of the literature did not reveal any equivalent cases. A comprehensive description of the management of this unusual course of spondylodiscitis is therefore presented here.

METHODS

Initially, the patient was suffering from L1-L2 spondylodiscitis caused by previous staphylococcal sepsis. After ineffective conservative antibiotic treatment, surgery was carried out, with posterior instrumentation and fusion at T11-L4 and removal and replacement of the L1 and L2 vertebral bodies.

RESULTS

After 2 months, the patient presented with paraparesis due to adjacent spondylodiscitis at T10-T11. The posterior instrumentation was therefore extended up to T9, and removal of the vertebral body of T11 was carried out. After 14 months, the patient was readmitted with pain and increased inflammatory parameters due to spondylodiscitis at T8/T9. Removal of the vertebral bodies was again carried out at T8 and T9, and posterior fusion up to T5 was performed. The patient received antibiotic treatment from 2 months before the first operation up to 3 months after surgery.

CONCLUSION

Newly developing spondylodiscitis adjacent to a level at which a previous spondylodiscitis has been treated surgically is a rare condition, and aggressive treatment is necessary.

Safety of instrumentation in patients with spinal infection

OBJECT

Treatment of spine infection remains a challenge for spine surgeons, with the most effective method still being a matter of debate. Most surgeons agree that in early stages of infection, antibiotic treatment should be pursued; under certain circumstances, however, surgery is recommended. The goals of surgery include radical debridement of the infective focus. In some cases, when surgery causes mechanical spinal instability, the question arises whether the risk of recurrent infection outweighs the benefits of spinal instrumentation and stabilization. The authors report their series of cases in which instrumentation was placed in actively infected sites and review the relevant literature.

METHODS

The authors performed a retrospective analysis of all cases of spinal infection that were surgically treated with debridement and placement of instrumentation at their institution between 2000 and 2006. Patient presentation, risk factor, infective organism, surgical indication, level of involvement, type of procedure, and ultimate outcome were reviewed. Improved outcome was based on improvement of initial American Spinal Injury Association Impairment Score.

RESULTS

Forty-seven patients (32 men, 15 women) were treated with instrumented surgery for spinal infection. Their average age at presentation was 54 years (range 37-78 years). Indications for placement of instrumentation included instability, pain after failure of conservative therapy, or both. Patients underwent surgery within an average of 12 days (range 1 day to 5 months) after their presentation to the authors' institution. The average length of hospital stay was 25 days (range 9-78 days). Follow-up averaged 22 months (range 1-80 months). Eight patients died; causes of death included sepsis (4 patients), cardiac arrest (2), and malignancy (2). Only 3 patients were lost to follow-up. Using American Spinal Injury Association scoring as the criterion, the patients' conditions improved in 34 cases and remained the same in 5. Complications included hematoma (2 cases), the need for hardware revision (1), and recurrent infection (2). Hardware replacement was required in 1 of the 2 patients with recurrent infection.

CONCLUSIONS

Instrumentation of the spine is safe and has an important role in stabilization of the infected spine. Despite the presence of active infection, we believe that instrumentation after radical debridement will not increase the risk of recurrent infection. In fact, greater benefit can be achieved through spinal stabilization, which can even promote accelerated healing.

Posterior transdiscal three-column shortening in the surgical treatment of vertebral discitis/osteomyelitis with collapse

STUDY DESIGN

Retrospective review of consecutive case series.

OBJECTIVE

To evaluate the early surgical results and complications of thoracic transdiscal osteotomies and vertebral shortening for the treatment of thoracic discitis/osteomyelitis.

SUMMARY OF BACKGROUND DATA

Thoracic discitis/osteomyelitis leads to collapse of the disc space and/or vertebral body. We propose a novel technique to achieve the same goals as anterior column reconstruction through an entirely posterior approach. Shortening of the vertebral column provides structural support without the morbidity of an anterior approach.

METHODS

Following REB approval, retrospective review of the charts of five patients that underwent posterior only thoracic transdiscal osteotomies and vertebral shortening for discitis/osteomyelitis was carried out. Posterior only surgery was performed in these patients with excision of the affected disc space and corresponding posterior elements. Instrumented fusion was performed across the segment spanning multiple vertebral levels. Clinical outcome, radiographic correction, and perioperative complications were analyzed.

RESULTS

Three patients had bacterial discitis, and 2 had tuberculosis. Mean age at the time of surgery was 61 years (50-76). Mean follow-up was 45 months (25-63). There was no neurologic deterioration; 2 patients with Frankel grade B improved to grade D and E, respectively. Mean kyphosis corrected from 36 degrees (14-90) to 4 degrees (0-8), and the mean construct spanned 9 levels (6-15). No major complications were encountered during surgery. Two patients underwent revision surgeries, 1 patient died of unrelated causes at 6 months. All patients were treated with a full course of postoperative antibiotic treatment. No cases of recurrent infection were recorded.

CONCLUSION

Thoracic transdiscal osteotomy with vertebral shortening is a safe and effective option for the treatment of infectious discitis/osteomyelitis with associated kyphosis. With adjuvant antibiotics, it effectively eradicates the infection through a posterior only approach, avoiding the need for anterior procedures and long anterior struts.

Clinical characteristics of infectious spondylodiscitis

Spondylodiscitis represents an inflammatory process, localized in the vertebrae body and in the intervertebral discs. The goals of this research were to identify subjective complaints, clinical findings, and laboratory characteristics in patients with spondylodiscitis, as well as to establish the importance of magnetic resonance imaging in diagnosing this disease. The data of 40 patients treated at the Clinic for Infectious diseases of the Clinical Center of Vojvodina from 2003 till 2007 were reviewed. Majority of the patients had low back pain (90%). Fever was present in 37.5% of patients (chi2 = 2.5; p > 0.05). Laboratory parameters of inflammation were higher than normal in most of the patients before the treatment. Diagnosis of spondylodiscitis was made using MRI in 97.5% of the patients. Keeping in mind unspecific subjective complaints and clinical findings in patients with spondylodiscitis, a health professional should always suspect spondylodiscitis when back pain occurs, in order to diagnose and treat this severe disease as early as possible. Magnetic resonance imaging is the most advantageous method in diagnosing spondylodiscitis.

Spinal Infection in Intravenous Drug Abusers

The number of intravenous (IV) drug abusers has been increasing in recent years. They are generally younger and healthier than the typical patient with a spinal infection. Reviewing the English language literature, there are only a few articles discussing the relationship between IV drug abuse and spinal infection. We studied 21 IV drug abusers with spinal infection. All were male, 19 were in their 30s and 40s with a mean age of 44 years. The mean follow-up period was 41 months after surgical intervention. Mild and severe neurologic deficit were seen in 5 and 13 patients (Frankel Grade C in 5, Grade D in 8), respectively. The overall positive culture rate was 17 out of 21 (81%). Twelve patients were infected with Staphylococcus aureus and 3 with Pseudomonas aeruginosa. Two had Mycobacterium tuberculosis. All were treated with anterior debridement and strut bone grafting with or without posterior instrumentation, laminectomy and abscess excision, or with additional discectomy. All patients with neurologic deficit recovered to a normal status. At the most recent follow-up, all the spine segments had fused and no one complained of any recurrent back pain. There were no postoperative complications. Physicians need to be more alert to the possibility of spinal infection in IV drug abusers with back pain. In addition to Staphylococcus aureus, Pseudomonas aeruginosa and Mycobacterium tuberculosis may be seen among IV drug abusers.

[Surgical management of spondylodiscitis. An analysis of 78 cases]

Spondylodiscitis is a rare bacterial infection of the spine with an inflammatory, destructive course. To obtain further information on the therapeutic management and clinical course of spondylodiscitis, we retrospectively investigated 78 patients after surgical intervention. Mean age was 64 years (+/-4.6 years; range 21-80 years), the mean length of stay 49 days (+/-8.2 days; 3-121 days) including 24 days (+/-4.7 days; 0-112 days) in ICU. In hospital mortality was 9%. The cervical spine was affected in 10%, the thoracic spine in 35% and the lumbar/sacral spine in 55% of patients. Abscess formation occurred in 65% and destruction of the vertebral body in 74%. A total of 75% of patients presented with neurological deficits which could be improved by surgical intervention in 82% of cases. 24 patients were treated by ventral debridement and stabilization alone, 20 patients with a combined dorsoventral method. Most patients (n=34) were stabilized via dorsal bridging instrumentation without ventral debridement of the focus. Of this group, 23 patients were initially scheduled for secondary ventral debridement but complete healing was achieved prior to this, so further surgical therapy was unnecessary. Successful cure was obtained in 92% of cases. Based on our findings, we favor a split surgical approach: initially with dorsal internal fixation only. Abscesses can be drained percutaneously. Ventral debridement and stabilization is only recommended if insufficient stability can be obtained by dorsal fixation alone, as shown by the persistence of infection or pain.

Surgical treatment of spondylodiscitis in the cervical spine: a minimum 2-year follow-up

Cervical spine spondylodiscitis is a rare, but serious manifestation of spinal infection. We present a retrospective study of 20 consecutive patients between 01/1994 and 12/1999 treated because of cervical spondylodiscitis. Mean age at the time of treatment was 59.7 (range 34-81) years, nine of them female. In all cases, diagnosis had been established with a delay. All patients in this series underwent surgery such as radical debridement, decompression if necessary, autologous bone grafting and instrumentation. Surgery was indicated if a neurological deficit, symptoms of sepsis, epidural abscess formation with consecutive stenosis, instability or severe deformity were present. Postoperative antibiotic therapy was carried out for 8-12 weeks. Follow-up examinations were performed a mean of 37 (range 24-63) months after surgery. Healing of the inflammation was confirmed in all cases by laboratory, clinical and radiological parameters. Spondylodesis was controlled radiologically and could be achieved in all cases. One case showed a 15 degrees kyphotic angle in the proximal adjacent segment. Spontaneous bony bridging of the proximal adjacent segment was observed in one patient. In the other cases the adjacent segments radiologically showed neither fusion nor infection related changes. Preoperative neurological deficits improved in all cases. Residual neurological deficits persisted in three of eight cases. The results indicate that spondylodiscitis in cervical spine should be treated early and aggressive to avoid local and systemic complications.

Surgical treatment with spinal instrumentation for pyogenic spondylodiscitis due to methicillin-resistant Staphylococcus aureus (MRSA): a report of five cases

INTRODUCTION

The treatment of methicillin-resistant Staphylococcus aureus (MRSA) spondylodiscitis is reported to be far more difficult than that of non-MRSA spondylodiscitis. At present, there seems to be no standard protocol for the treatment of MRSA spondylodiscitis cases in which conservative management has failed.

MATERIALS AND METHODS

Between 1998 and 2001, five patients (aged 48-73 years; average: 63.8 years; SD: 9.9) with MRSA spondylodiscitis were treated surgically after conservative treatment had failed. Posterior spinal instrumentation was performed for all five patients, three of whom also underwent anterior debridement and bone graft. All the patients had neurological deficits and severe pain. To assess the invasiveness of the operation, we evaluated operating time, blood loss, and complications. Pain (verbal rating scale; VRS), neurological status (Frankel type), activities of daily living (ADL) (the Barthel index), WBC, CRP, and ESR in the preoperative, postoperative and final follow-up periods were used to evaluate the surgical outcomes.

RESULTS

Although we encountered several postoperative complications including deep wound infections, at the final follow-up visit, the neurological deficits, activities of daily living, Barthel index, and VRS had improved in all the patients. Changes in WBC, CRP, and ESR revealed suppression of infection in all patients.

CONCLUSION

Surgical treatment for MRSA spondylodiscitis with posterior spinal instrumentation provided patients with satisfactory final outcomes.

Pyogenic spinal infections and outcome according to the 36-Item Short Form Health Survey

Object

Pyogenic vertebral infections are rare. In most papers investigators have focused on risk factors, clinical characteristics, and diagnostic findings, and discussed different management strategies. The optimal strategy for dealing with spinal infections, however, remains controversial. Additionally, outcome data regarding quality of life (QOL) after pyogenic spinal infections are sparse. The aim of this study was to provide further data in this field.

Methods

The authors retrospectively investigated 62 patients suffering from pyogenic spinal infections. In 37 patients (59%), lumbar lesions were observed; thoracic and thoracolumbar infections were documented in 19 (31%) and a cervical infection was demonstrated in six patients (10%). Overall 28 patients (45%) underwent conservative treatment, and 34 (55%) underwent surgery with or without the placement of instrumentation. At follow-up examination the authors recorded each patient’s satisfaction as well as QOL according to the 36-Item Short Form Health Survey. Quality of life after treatment of pyogenic spine infections did not reach the level of the normative sample. Most patients continued to suffer some sort of pain. Despite different indications, the surgically treated patients experienced a slightly better QOL and self-reported satisfaction levels, as well as a statistically significant better outcome, than patients treated conservatively.

Conclusions

The results obtained in the present study suggest that surgery, especially in conjunction with the placement of instrumentation, may be more beneficial than conservative treatment in patients with a spinal infection.

[Multistep surgery for spondylosyndesis. Treatment concept of destructive spondylodiscitis in patients with reduced general condition]

OBJECTIVE

Retrospective assessment of multistage surgery in the treatment of progressive spondylodiscitis in patients with critical physical status.

PATIENTS

A total of 34 patients (mean age 58.6 years) with 37 progressive spondylodiscitis foci and destruction of one to three vertebral segments (1.9 mean) were recorded within an 8-year period. Time between first complaints and operative treatment was 3 months (mean). Preoperative health status was critically reduced in 11 patients (ASA IV) and poor general condition (ASA III) was seen in 23 patients when vital indication was seen preoperatively. Considerable systemic disease (n=31), further infection focus (n=18), and nosocomial trauma (n=5) were causally related. Spondylodiscitis was seen more frequently in the lumbar (n=20) and thoracolumbar than in the thoracic (n=10) and cervical spine (n=1). Staphylococcus aureus was detectable from operative specimens and hemoculture in 15 cases, MRSA in 6 of these.

METHODS

In cases of monosegmentary involvement (n=7) ventral debridement, biopsy, and application of antibiotic chains were followed by autologous interbody bone grafting in a second stage operation. In 29 cases with destruction of two (n=27) and three (n=3) segments, posterior instrumentation including laminectomy in 4 patients was completed by anterior debridement and application of antibiotic chains during a first surgical intervention. After stabilization of physical condition and having reached a macroscopically indisputable implant bed, the ventral fusion with autologous interbody bone grafting or cage in combination with a plate or internal fixation system was performed as the last of several surgical steps.

RESULTS

No case of perioperative mortality was observed. Intensive care continued 9.1 days and hospitalization 49.5 days (mean). During a 37.6-month follow-up two late recurrences were observed.

CONCLUSION

A multistep surgical procedure under protection of dorsal instrumentation can limit perioperative mortality in patients in critical general condition by avoiding an extended one stage dorsoventral spondylodesis. After eradication of further infection foci and stabilization of physical condition, ventral instrumentation is completed under elective conditions.

Nonspecific pyogenic spondylodiscitis: clinical manifestations, surgical treatment, and outcome in 24 patients

Object

Pyogenic vertebral osteomyelitis is of special interest to neurosurgeons because it often results in acute neurological deterioration and requires a combination of adequate surgical and conservative treatment. The aim of the current study was to evaluate the strategy of a primary surgical approach to this disease.

Methods

A group of 24 patients with the clinical and radiological signs of acute pyogenic spondylodiscitis was prospectively followed from 1998 to 2004. Of these, 20 had underlying diseases such as diabetes mellitus, chronic alcoholism, and liver cirrhosis. The main causative organism wasStaphylococcus aureus.Most infections were localized in the thoracic or lumbar spine (10 cases each); 15 infections were associated with epidural abscesses. Because of a delay in diagnosis, 13 patients presented with neurological deficits on admission.

Patients with a complete or rapidly progressing neurological deficit underwent immediate surgery. In patients with minor or no deficits or in a stable neurological condition, surgery was delayed for 3 to 5 days. This group was treated with immobilization and intravenous antibiotic drugs before surgery. Surgical procedures included ventral, dorsal, and combined approaches in one- or two-stage operations. Antibiotic treatment included the use of broad-spectrum antibiotic drugs delivered intravenously for at least 10 days, followed by orally administered antibiotics for 3 months.

Twenty patients were independent on follow-up review, 15 with no or minor handicaps. Severe septicemia and multiorgan failure developed in two patients, and these two died of their disease. Major complications were mainly due to long-term antibiotic therapy.

Conclusions

Surgical treatment is the modality of choice in patients with acute spinal osteomyelitis. It is especially indicated in patients with progressive or severe neurological deficits and spinal deformity. In experienced hands, surgery is safe and offers the advantages of spinal cord decompression, immediate mobilization, and correction of spinal deformity. The decision whether an anterior or posterior approach should be used must be made on an individual basis.

Surgical treatment of spondylodiscitis

BACKGROUND

Spondylodiscitis is a rare bacterial infection of the vertebra and intervertebral discs with an inflammatory, destructive course.

METHODS

To gain further information about the management and clinical course of spondylodiscitis, we retrospectively reviewed 32 patients in 2002 who had surgical interventions between 1992 and 2001.

RESULTS

The mean age of patients was 61 years (29-78 years). The mean hospital stay was 47 days (+/- 5.6 days; 3-121 days), including 28 days (+/- 8.1 days; 2-112 days) in the ICU. In-hospital mortality was 6%. The cervical spine was affected in 20% of patients (6/32), the thoracic spine in 25% (8/32), and the lumbosacral spine in 55% (18/32). Abscesses occurred in 63% of patients (20/32) and destruction of the vertebral body in 71% (23/32). Neurological deficits were present in 17 patients, which improved by surgical intervention in 82% of those affected. Thirty-one patients underwent ventral resection of the focus, spondylodesis with a bone graft or titanium cage, and ventral stabilization with a plate. In 19% of patients (6/32), additional dorsal bridging instrumentation was performed. Complete healing was obtained in 94% (30/32) patients. At follow-up, 50% of patients (16/32) had no complaints.

CONCLUSIONS

Spondylodiscitis requires immediate debridement of the focus, with decompression and stabilization through a ventral approach, when conservative management fails. Otherwise, severe complications occur, such as sepsis, vertebral body destruction, abscess, or neurological deficits.

Polysegmental spondylodiscitis and concomitant aortic aneurysm rupture: case report with 3-year follow-up period

STUDY DESIGN

A case report describing a patient with spondylodiscitis of the thoracic and lumbar spine complicated by rupture of an abdominal aortic aneurysm and aggravation of neurologic symptoms is presented.

OBJECTIVE

To present a cardiovascular complication worsening the clinical condition during conservative spondylodiscitis therapy, and to describe a minimally invasive treatment regimen for both spondylodiscitis and aortic aneurysm rupture in multimorbid patients at high risk for complications or refusal of surgery.

SUMMARY OF BACKGROUND DATA

Few articles describe minimally invasive treatment of spondylodiscitis. Some available reports describe neurologic symptoms resulting from spinal cord ischemia in aortic aneurysm rupture. No data were found describing simultaneous therapy for spondylodiscitis and rupture of aortic aneurysm.

METHODS

Therapy consisted of CT-guided percutaneous drainage of the spondylodiscitis and parenteral antibiotic treatment combined with immobilization and minimally invasive endoluminal exclusion of the aortic aneurysm with a bifurcated stent graft.

RESULTS

Effective therapy for polysegmental spondylodiscitis on the one hand and contained rupture of aortic aneurysm on the other are presented. The successful clinical outcome after conservative orthopedic therapy and vascular intervention has been followed for 3 years.

CONCLUSIONS

In older patients, spondylodiscitis may be complicated by other underlying diseases. Pain and neurologic symptoms may occur secondarily to concomitant illnesses instead of being caused by the inflammation itself. Minimally invasive therapy is shown to be an effective alternative to surgery in older and multimorbid patients with spondylodiscitis and contained aortic aneurysm rupture.

Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages

There is no scientific consensus on the role of posterior instrumentation in vertebral osteomyelitis. No study has examined the use of titanium cages to reconstruct the anterior column of the spine with vertebral osteomyelitis. Here the authors evaluated the efficacy of using titanium mesh cages anteriorly and posterior instrumentation after anterior debridement in the surgical treatment of vertebral osteomyelitis. In one center, 21 consecutive patients had surgery for vertebral osteomyelitis. The mean follow-up time was 67 months (range, 24 to 120 months). Ten patients received supplemental posterior instrumentation. Five patients had reconstruction of the anterior column with titanium cages. Greater improvement in sagittal alignment was noted for patients with cages implanted (p = 0.0009) and for those with posterior instrumentation (p = 0.005). Patients who received cages had greater (p = 0.0006) correction of their coronal alignment than did those patients without cages. A trend toward fewer postoperative complications emerged for patients who had posterior stabilization or titanium cages. These results support the use of posterior stabilization and titanium cages in the surgical treatment of vertebral osteomyelitis.