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

Early fusion outcome after surgical treatment of single-level and multi-level pyogenic spondylodiscitis: experience at a level 1 center for spinal surgery-a single center cohort study

STUDY DESIGN

Retrospective single center cohort study.

PURPOSE

Spinal instrumentation in combination with antibiotic therapy is a treatment option for acute or chronic pyogenic spondylodiscitis (PSD). This study compares the early fusion outcome for multi-level and single-level PSD after urgent surgical treatment with interbody fusion in combination with fixation.

METHODS

This is a retrospective cohort study. Over a 10 year period at a single institution, all surgically treated patients received surgical debridement, fusion und fixation of the spine to treat PSD. Multi-level cases were either adjacent to each other on the spine or distant. Fusion rates were assessed at 3 and 12 months after surgery. We analyzed demographic data, ASA status, duration of surgery, location and length of spine affected, Charlson comorbidity index (CCI), and early complications.

RESULTS

A total of 172 patients were included. Of these, 114 patients suffered from single-level and 58 from multi-level PSD. The most frequent location was the lumbar spine (54.0%) followed by the thoracic spine (18.0%). The PSD was adjacent in 19.0% and distant in 81.0% of multi-level cases. Fusion rates at the 3 month follow-up did not differ among the multi-level group (p = 0.27 for both adjacent and distant sites). In the single-level group, sufficient fusion was achieved in 70.2% of cases. Pathogen identification was possible 58.5% of the time.

CONCLUSIONS

Surgical treatment of multi-level PSD is a safe option. Our study demonstrates that there was no significant difference in early fusion outcomes between single-level and multi-level PSD, whether adjacent or distant.

[Spondylodiscitis]

Spondylodiscitis is an infection of the spine that first affects the vertebral endplates ("spondylitis") and then spreads to the adjacent intervertebral disc ("spondylodiscitis"). As it is a potentially life-threatening systemic disease rapid, often surgical treatment is required. Due to the multimorbidity of the patients and the complexity of the therapy, a multidisciplinary approach is essential. The vast majority of the cases heals under conservative therapy. An absolute indication for surgical therapy is given for acute septic courses or if there are new relevant neurological deficits. In addition, urgent surgical treatment is required for epidural abscesses that can be diagnosed by means of magnetic resonance imaging. In developed countries, over 90% of all spondylodiscitis cases come to a complete recovery.

Novel rat tail discitis model using bioluminescent Staphylococcus aureus

Management of spondylodiscitis is a challenging clinical problem requiring medical and surgical treatment strategies. The purpose of this study was to establish a rat model of spondylodiscitis that utilizes bioluminescent Staphylococcus aureus (S. aureus), thus permitting in vivo surveillance of infection intensity. Inocula of the bioluminescent S. aureus strain XEN36 were created in concentrations of 10² CFU/0.1 ml, 10⁴  CFU/0.1 ml, and 10⁶  CFU/0.1 ml. Three groups of rats were injected with the bacteria in the most proximal intervertebral tail segment. The third most proximal tail segment was injected with saline as a control. Bioluminescence was measured at baseline, 3 days, and weekly for a total of 6 weeks. Detected bioluminescence for each group peaked at day 3 and returned to baseline in 21 days. The average intensity was highest for the experimental group injected with the most concentrated bacterial solution (10⁶  CFU/0.1 ml). Radiographic analysis revealed loss of intervertebral disc space and evidence of osseous bridging. Saline-injected spaces exhibited no decrease in intervertebral spacing as compared to distal sites. Histologic analysis revealed neutrophilic infiltrates, destruction of the annulus fibrosus and nucleus pulposus, destruction of vertebral endplates, and osseous bridging. Saline-injected discs exhibited preserved annulus fibrosus and nucleus pulposus on histology. This study demonstrates that injection of bioluminescent S. aureus into the intervertebral disc of a rat tail is a viable animal model for spondylodiscitis research. This model allows for real-time, in vivo quantification of infection intensity, which may decrease the number of animals required for infection studies of the intervertebral disc. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2075-2081, 2017.

Early surgery with antibiotics treatment had better clinical outcomes than antibiotics treatment alone in patients with pyogenic spondylodiscitis: a retrospective cohort study

Background

Pyogenic spondylodiscitis is a form of spinal infection that can result in severe back pain and even death. However, information is lacking on the relative effectiveness of various therapies. A retrospective chart review was conducted to investigate whether early surgical treatment of pyogenic spondylodiscitis coupled with intravenous antibiotics results in better patient prognoses than intravenous antibiotics therapy alone.

Methods

All patients treated for pyogenic spondylodiscitis at a single medical center from July 2006 to July 2011 were retrospectively reviewed. The inclusion criteria consisted of diagnosis of an early stage infection without neurological deficit, and patients without severe sepsis who were suitable candidates for early surgery as determined by a Pittsburgh bacteremia score < 4, and patients with delayed diagnosis and lost to outpatient follow-up were excluded. Clinical outcomes included patient demographic data, kyphosis angle, length of treatment, Oswestry Disability Index and visual analogue pain scale were analyzed.

Results

Of 90 enrolled patients, Group 1 (n = 47) received only antibiotic therapy and Group 2 (n = 43) received early surgery with post-surgery antibiotics for 2 to 4 weeks. Group 2 exhibited significantly better results than Group 1 for mean antibiotic administration period, mean hospitalization period, kyphotic angle correction. Of 61 patients who participated in telephone follow-up after discharge, Group 2 (n = 26) had significant lower mean ODI score, and mean back pain score than Group 1 (n = 35).

Conclusions

While infection control was similar for both groups, patients treated with early surgery and antibiotics were hospitalized for fewer days and required less antibiotics than those treated with antibiotics alone, also having better functional outcomes. In short, early surgical treatment of pyogenic spondylodiscitis typically achieves a better prognosis, shorter hospitalization period, and subsequent significant improvement in kyphotic deformity and quality of life.

Cervical osteomyelitis with thoracic myelitis and meningitis in a diabetic patient

A 45-year-old man with a history of untreated diabetes mellitus had a persisting fever, back pain, and diarrhea. The primary care physician diagnosed the patient with the flu and gastroenteritis. The patient developed paraplegia for two weeks and was admitted to another hospital. The physician in this hospital suspected infectious meningitis and myelitis, and administered piperacillin and steroids without cerebrospinal fluid (CSF) examination. On referral to our hospital, he presented a high fever and complete paraplegia. The lumbar puncture revealed a yellowish CSF, polynucleosis, and hypoglycorrhachia. Bacteria were not detected on Gram's staining and were not confirmed by CSF culture. Magnetic resonance imaging (MRI) showed no thoracolumbar lesion and suggested a cervical epidural abscess without any spinal cord compression. He was diagnosed as having osteomyelitis with meningitis and thoracic myelitis. The infection subsided with broad-spectrum antibiotics. After two weeks, bilateral sensorimotor disturbances of the upper extremities appeared. MRI findings showed the epidural abscess compressing the cervical spinal cord. We performed debridement of the epidural abscess. The infection was clinically controlled by using another antibiotic. One month after the infection subsided, a 360° reconstruction was performed. In this case, the misdiagnosis and the absence of CSF examination and culture to detect the pathogenic bacteria at an earlier stage in the patient's disease course might have led to the exacerbation of the pathology.

[Pyogenic spondylodiscitis: therapy algorithm and a new classification for therapeutic decision-making]

The incidence of pyogenic spondylodiscitis is low but has been steadily increasing in recent years. To date there has been no consensus concerning selection of the appropriate treatment, management and strategies and the recommendations for an operative strategy are still a highly controversial issue. In the literature a few statements have been published concerning therapeutic decision-making in pyogenic spondylodiscitis. The classification given in this article is based on clinical experience and retrospective data analysis considering the degree of segmental bony destruction, grade of kyphosis and instability, epidural involvement of the disease and neurological deficits, which are pivotal for therapeutic decision-making. The therapeutic procedure can be defined based on this classification.

Treatment of spondylodiscitis

PURPOSE

Pyogenic infections of the spine are relatively rare with an incidence between 1:100,000 and 1:250,000 per year, but the incidence is increasing due to increases in average life-expectancy, risk factors, and medical comorbidities. The mean time in hospital varies from 30 to 57 days and the hospital mortality is reported to be 2-17%. This article presents the relevant literature and our experience of conservative and surgical treatment of pyogenic spondylodiscitis.

METHOD

We have performed a review of the relevant literature and report the results of our own research in the diagnosis and treatment of pyogenic spondylodiscitis. We present a sequential algorithm for identification of the pathogen with blood cultures, CT-guided biopsies and intraoperative tissue samples. Basic treatment principles and indications for surgery and our surgical strategies are discussed.

RESULTS

Recent efforts have been directed toward early mobilisation of patients using primary stable surgical techniques that lead to a further reduction of the mortality. Currently our hospital mortality in patients with spondylodiscitis is around 2%. With modern surgical and antibiotic treatment, a relapse of spondylodiscitis is unlikely to occur. In literature the relapse rate of 0-7% has been recorded. Overall the quality of life seems to be more favourable in patients following surgical treatment of spondylodiscitis.

CONCLUSION

With close clinical and radiological monitoring of patients with spondylodiscitis, conservative and surgical therapies have become more successful. When indicated, surgical stabilisation of the infected segments is mandatory for control of the disease and immediate mobilisation of the patients.

Complex 360°-reconstruction and stabilization of the cervical spine due to osteomyelitis

Osteomyelitis of the cervical spine may lead to profound bony destruction. The presented case developed multilevel osteomyelitic destruction of the cervical spine after decompression due to cervical myelopathy. He could be cured by a multiple-stage procedure: step one: debridement and removal of all anterior implants with vacuum-assisted closure combined with dorsal instrumentation from C0 to T3; step two: anterior reconstruction with expandable titanium cages and plate. The patient regained walking with the aid of a walking frame. The following recommendations are given: multiple stage procedure, extensive debridement and stabilization via an anterior and posterior approach, use of titanium implants.

Treatment of spondylodiscitis in human immunodeficiency virus-infected patients: a comparison of conservative and operative therapy

STUDY DESIGN

Multicenter retrospective case series.

OBJECTIVE

To determine relevant clinical presentation and outcome of human immunodeficiency virus (HIV)-positive patients with spondylodiscitis as a function of the treatment.

SUMMARY OF BACKGROUND DATA

This is the first study comparing the clinical outcome of HIV-positive patients with spondylodiscitis as a function of the treatment.

METHODS

We performed a national multicenter retrospective case series comparing operatively versus conservatively treated HIV-positive patients with spondylodiscitis presenting between 1991 and 2007.

RESULTS

Twenty patients were included in the study. The average age of the patients at the time of admission was 43.0 years. The sex ratio m:w resulted in 2.3:1. On admission, 50% of the patients were in CDC stage C3. The CD4 T-cell count was determined as being 237.5/microL on average. At the occurrence of spondylodiscitis HIV had been known for a mean 8.5 years. In altogether 75% of the cases a pathogen was found. In 3 cases, mixed infections were present. Half of the patients received surgery. In none of these patients a wound infection or a delay of wound healing could be observed. One patient died during in-patient stay. Eleven of the 19 patients could be followed up a mean 13 months after discharge. In the follow-up period further 3 patients died on an average of 45 months after discharge.

CONCLUSION

The occurrence of spondylodiscitis in HIV-positive patients is associated with a low CD4 T-cell count. The probability of mixed infections rises with a CD4 T-cell count <100/microL. The occurrence of spondylodiscitis in HIV-positive patients is accompanied by high mortality. Operative therapy of spondylodiscitis in HIV-positive patients is not associated with an increased surgical complication rate. HIV infection or AIDS should not have an influence on decision-making regarding conservative or operative therapy of spondylodiscitis.

[Operative therapy of bacterial spondylodiscitis: a retrospective study]

OBJECTIVE

Bacterial spondylodiscitis is a rare entity in spinal surgery. This study analyses the postoperative results of 53 patients, focusing on the history, the treatment, and the course of the disease.

MATERIAL AND METHODS

This retrospective study is based on the patients' medical charts, including the laboratory and microbiological data.

RESULTS

Twenty-nine patients suffered from different neurological deficits ranging from isolated mild hypaesthesia (n=1) to complete paraplegia (n=6). Depending on the affected area and the extension of the infection, surgery was done either as simple decompression in 16 cases or as decompression combined with a ventral or dorsoventral stabilization in 37 patients. Staphylococcus aureus was the most important triggering organism (n=23). After a median follow-up of 11.25 months, three patients had died, and 22 patients were still disabled because of persisting pain or neurological disturbances.

CONCLUSION

Because of persistent neurological deficits and possible lethal complications, spondylodiscitis remains a severe problem. Management comprises targeted antibiotic therapy and surgery in selected cases.

[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.