Epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine; evaluation of a new MRI staging classification and imaging findings as indicators of surgical management: a retrospective study of 37 patients

Predictors of conversion surgery after conservative treatment for pyogenic spondylitis

BACKGROUND

Patient demographic and clinical characteristics may be factors associated with the success of conservative treatment for pyogenic spondylitis. The ability of imaging findings at initial diagnosis to predict patient outcomes remains unclear. The aim of this study was to investigate the risk factors associated with conversion surgery after conservative treatment for pyogenic spondylitis, with a special focus on the initial computed tomography (CT) findings.

METHODS

This study enrolled 35 patients with pyogenic spondylitis who underwent CT and magnetic resonance imaging (MRI) at diagnosis and were followed-up for more than 6 months. Patients were diagnosed by MRI, and the degree of bone destruction was assessed on CT cross-sectional images. Vertebral body destruction was classified as grades 0 (almost normal), 1 (endplate irregularity), 2 (vertebral body destruction not involving the posterior wall), and 3 (destruction involving the posterior wall). Patients were divided into four groups based on grade of bone destruction and their clinical characteristics were compared.

RESULTS

1, 11, 11, and 12 patients were classified as grades 0, 1, 2, and 3, respectively. Univariate analysis showed no significant differences in the demographic and clinical characteristics of the four groups. Eighteen (51.4 %) patients had been treated surgically, with the rate of surgical treatment being significantly higher in patients with grade 3 (83.3 %) than in those with grades 0 + 1 (25 %) and grade 2 (45.5 %) (P < 0.05). Multivariate analysis showed that epidural abscess on MRI (odds ratio [OR] 10.8, 95 % confidence interval [CI] 1.68-69.7), grade 3 bone destruction on CT (OR 3.97, 95 % CI 1.21-13.0), and C-reactive protein (CRP) improvement rate after 1 week of treatment (OR 0.95, 95 % CI 0.91-0.99) were risk factors for surgery.

CONCLUSIONS

Early surgical treatment should be considered for patients with pyogenic spondylitis who present with an epidural abscess on MRI and bone destruction extending to the posterior wall on CT at the time of diagnosis.

Early Reduction in C-Reactive Protein Following Treatment for Spinal Epidural Abscess: A Potential Treatment Guide

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

To assess the predictive value of early C-reactive protein (CRP) trends following diagnosis of spinal epidural abscess (SEA). Non-operative management with intravenous antibiotics has not demonstrated equivalent outcomes with regard to mortality and morbidity. Knowledge of specific patient and disease factors associated with worse outcomes may predict treatment failure.

METHODS

All patients treated for spontaneous SEA in a tertiary centre in New Zealand over a 10-year period were followed for at least 2 years. CRP at diagnosis and day 4-5 following treatment initiation was analyzed to determine predictors of CRP reduction of at least 50%. Proportional Cox hazards regression investigated mortality over 2 years.

RESULTS

94 patients met inclusion criteria and with CRP values available for analysis. Median age was 62 years (+/- 17.7) and 59 (63%) were treated operatively. Kaplan-Meier analysis estimate of 2-year survival was .81 (95% CI .72-.88). CRP reduction by 50% was seen in 34 patients. Patients who did not experience a 50% reduction were more likely to have thoracic infection (27 vs 8, P = .02) or multifocal sepsis (41 vs 13, P = .002). Failure to achieve a 50% reduction by day 4-5 was associated with worse post-treatment Karnofsky scores (70 vs 90, P = .03) and longer hospital stay (25 days vs 17.5 days, P = .04). Cox regression model showed mortality predicted by Charlson Comorbidity Index, thoracic location of infection, pre-treatment Karnofsky score, and failure to achieve a 50% CRP reduction by day 4-5.

CONCLUSIONS

Patients who fail to reduce CRP values by 50% at day 4-5 following treatment initiation are more likely to experience prolonged hospital stay, have poorer functional outcome and have greater mortality risk at 2 years. This group has severe illness regardless of treatment type. Failure to achieve a biochemical response to treatment should prompt reassessment.

Factors associated with the time required for CRP normalization in pyogenic spondylitis: A retrospective observational study

Background

Treatment for pyogenic spondylitis tends to be prolonged; however, few studies have examined the factors associated with the time required for infection control. Therefore, we analyzed a consecutive cohort of patients to identify factors associated with the time required to control infection in pyogenic spondylitis. This study aimed to clarify the factors linked to the duration necessary for achieving infection control in cases of pyogenic spondylitis, using C-reactive protein (CRP) normalization as an indicator.

Methods

In this retrospective observational study, we investigated 108 patients diagnosed with pyogenic spondylitis. We evaluated the number of days from the first visit to CRP normalization; for cases wherein CRP did not normalize, the number of days to the date of final blood sampling was evaluated. In the present study, infection control in pyogenic spondylitis was defined as a CRP falling within the normal range (≤0.14 mg/dL). We performed univariate and multivariate Cox regression analyses to identify various factors associated with the time required for CRP normalization in pyogenic spondylitis.

Results

The mean time required for CRP normalization was 148 days. Univariate Cox regression analysis showed that the serum creatinine level, estimated glomerular filtration rate (eGFR), lymphocyte percentage, neutrophil percentage, CRP level, CRP-albumin ratio, and neutrophil-to-lymphocyte ratio were significantly associated with the time required to control infection. Multivariate Cox regression analysis showed that a higher neutrophil percentage, diabetes mellitus, and a lower eGFR were the independent factors associated with a longer infection control time.

Conclusions

We found that a higher neutrophil percentage, diabetes mellitus, and a lower eGFR were significantly associated with a longer time for CRP normalization in pyogenic spondylitis. These findings may help identify patients with pyogenic spondylitis who are at a high risk for an extended infection control period.

A Comprehensive Review of Pyogenic Spondylitis Management for Neurosurgeons

Older populations have been increasing recently, resulting in an increase in cases of pyogenic spondylitis. Neurosurgeons who frequently treat the elderly are at a higher risk of encountering this condition. Therefore, this article provides a summary of the literature and our experience to help neurosurgeons effectively manage pyogenic osteomyelitis. It is important not to rule out pyogenic spondylosis when examining a patient with back pain, even in the absence of a fever. This is because the chronic type is common, easily overlooked, and early diagnosis and treatment are crucial. Empirical antibiotics should be avoided in cases where blood culture and biopsy are negative, to prevent microbial resistance and an increase in difficult-to-treat cases. Biopsies, such as computed tomography-guided percutaneous biopsy and full endoscopic debridement and drainage, should be attempted. Currently, 6 weeks of parenteral antibiotic therapy is the main treatment for pyogenic spondylitis. Surgical treatment is recommended if this method is ineffective. However, in the early stages, full endoscopic debridement and drainage and percutaneous pedicle screw fixation are optional.

Conservative versus early surgical treatment in the management of pyogenic spondylodiscitis: a systematic review and meta-analysis

Spondylodiscitis is the commonest spine infection, and pyogenic spondylodiscitis is the most common subtype. Whilst antibiotic therapy is the mainstay of treatment, some advocate that early surgery can improve mortality, relapse rates, and length of stay. Given that the condition carries a high mortality rate of up to 20%, the most effective treatment must be identified. We aimed to compare the mortality, relapse rate, and length of hospital stay of conservative versus early surgical treatment of pyogenic spondylodiscitis. All major databases were searched for original studies, which were evaluated using a qualitative synthesis, meta-analyses, influence, and regression analyses. The meta-analysis, with an overall pooled sample size of 10,954 patients from 21 studies, found that the pooled mortality among the early surgery patient subgroup was 8% versus 13% for patients treated conservatively. The mean proportion of relapse/failure among the early surgery subgroup was 15% versus 21% for the conservative treatment subgroup. Further, it concluded that early surgical treatment, when compared to conservative management, is associated with a 40% and 39% risk reduction in relapse/failure rate and mortality rate, respectively, and a 7.75 days per patient reduction in length of hospital stay (p < 0.01). The meta-analysis demonstrated that early surgical intervention consistently significantly outperforms conservative management in relapse/failure and mortality rates, and length of stay, in patients with pyogenic spondylodiscitis.

Spondylodiscitis in Geriatric Patients: What Are the Issues?

STUDY DESIGN

Review article.

OBJECTIVES

A review of literature on the treatment of pyogenic spondylodiscitis in geriatric patients was performed with the aim to give an overview about these special patients and a recommendation on necessary diagnostics as well as conservative and operative treatment options.

METHODS

A systematic computerized literature search was done by the spondylodiscitis working group of the German Society for Orthopedics and Trauma Surgery.

RESULTS

Spondylodiscitis has an increasing incidence by age with a peak at 75 years or older. The 1-year mortality without an appropriate treatment is with 15 to 20% extremely high. Pathogen detection is the essential diagnostic step and the basis for a sufficient antibiotic treatment. Geriatric patients have initially less elevated inflammatory parameters. Compared to younger patients. They have a longer length of hospital stay and take longer for CRP normalization. Even the outcome between conservative and operative treatment is comparable after one year. Patients with spinal instability, immobilizing pain, epidural abscess, and newly emerged neurological deficits should be considered for operative treatment.

CONCLUSIONS

The treatment of geriatric patients with pyogenic spondylodiscitis must take into account that these patients usually have multiple comorbidities. The main goals are resistance-based antibiotics and the shortest possible time of immobilization of the patient.

The Role of Diskectomy in Reducing Infectious Complications after Surgery for Lumbar Spondylodiscitis

BACKGROUND

 Surgery for pyogenic Spondylodiscitis as an adjunct to antibiotic therapy is an established treatment. However, the technique and extent of surgical debridement remains a matter of debate. Some propagate diskectomy in all cases. Others maintain that stand-alone instrumentation is sufficient.

METHODS

 We reviewed charts of patients who underwent instrumentation for pyogenic Spondylodiscitis with a minimum follow-up of 1 year. Patients were stratified according to whether they underwent diskectomy plus instrumentation or posterior instrumentation alone. Outcome measures included the need for surgical revision due to recurrent epidural intraspinal infection, wound revision, and construct failure.

RESULTS

 In all, 257 patients who underwent surgery for pyogenic Spondylodiscitis were identified. Diskectomy and interbody procedure (group A) was performed in 102 patients, while 155 patients underwent instrumentation surgery for Spondylodiscitis without intradiskal debridement (group B). The mean age was 67 ± 12 years, and 102 patients (39.7%) were females. No significant differences were found in the need for epidural abscess recurrence therapy (group A [2.0%] and 5 cases in group B [3%; p = 0.83]) and construct failure (p = 0.575). The need for wound revisions showed a tendency toward higher rates in the posterior instrumentation-only group, which failed to reach significance (p = 0.078).

CONCLUSIONS

 Overall, intraspinal relapse of surgically treated pyogenic diskitis was low in our retrospective series. The choice of surgical technique was not associated with a significant difference. However, a somewhat higher rate of wound infections requiring revision in the group where no diskectomy was performed has to be weighed against a longer duration of surgery in an already ill patient population.

Case Report: A case of cervical spinal epidural abscess combined with cervical paravertebral soft tissue abscess

Background

Spinal epidural abscess (SEA) is a rare purulent infection of the central nervous system. Abscesses confined to the spinal canal can compress the spinal cord, causing nerve damage and even death in severe cases (1). Prompt diagnosis and treatment can relieve symptoms and prevent complications. To increase awareness of this rare disease, we report a case of a 58-year-old man with a cervical spinal epidural abscess combined with a soft tissue abscess in the neck and describe its clinical course, imaging feature, pathology, treatment, and patient prognosis.

Case description

A 58-year-old male Chinese patient was admitted to our hospital because of neck pain for 2 months, which worsened for 4 days. On the third day of admission, the muscle strength of the limbs decreased, and MRI of the spinal cord showed abnormal signal shadows in the spinal canal at the C1-C7 level and in the surrounding soft tissue on the right side of spine, suggesting the possibility of inflammatory lesions with local abscess formation. We immediately performed decompression of the spinal canal on the patient and performed incision and drainage of the cervical abscess. During the operation, we found a large amount of pus in the epidural space of the spinal canal, and there was a fistula between the cervical abscess and the epidural abscess of the spinal canal. The patient underwent continuous drainage and anti-infective treatment with sensitive antibiotics after operation. No recurrence of the abscess was observed and the patient recovered well.

Conclusion

Early diagnosis is the key to the treatment of SEA, so radiologists and neurosurgeons need to strengthen their understanding of this rare disease to avoid misdiagnosis. For SEA with definite diagnosis, decompression surgery should be performed in a timely manner when symptoms of nerve compression occur, continuous drainage should be performed after surgery, and sensitive antibiotics should be used for anti-infective treatment.

MORPHOLOGICAL ASPECT OF PYOGENIC SPINAL EPIDURAL ABSCESSES. PART I

ABSTRACT Background: Pyogenic Spinal Epidural Abscess (PSEA) is difficult to diagnose and can have devastating consequences. Magnetic Resonance Imaging (MRI) has high sensitivity and specificity, which are further increased with the use of contrast. There are several classifications of vertebral infectious processes, with emphasis on spondylodiscitis. Objective: To analyze the morphological parameters and their reproducibility; and to analyze different resonance imaging sequences. Methods: Using an image database, a morphological classification of PSEA was planned, with five parameters: Region (R), indicating the upper and lower limits of the abscess; Location (U), indicating whether the abscess is anterior or posterior within the canal; Compromise (C), meningeal or content of the structures; Association (A), discitis, osteomyelitis or both; and Perivertebral (P), anterior, lateral or posterior extravertebral abscess. The first three parameters give an idea of the volume of the PSEA, while the last two give the related infectious foci. Thirty-five cases were analyzed using Kappa’s coefficient. Results: The global intra- and interobserver reproducibility was Kappa 0.81. The results for each parameter were as follows: R=0.95, U=0.92, C=0.66, A=0.70 and P=0.80. The first three give a notion of volume and the last two relate to the presence of vertebral infectious foci outside the canal. T2 weighted MRI with contrast was found to be the most effective imaging sequence. Conclusion: The morphological classification is simple to use, with excellent reproducibility. The parameters with the highest reproducibility were region and location, with values >0.92. The addition of gadolinium contrast increased the sensitivity of the diagnosis; the use of sagittal and axial images in T2-MRI was the most sensitive imaging sequence. Evidence Level III; Original.

Risk factors for residual neurologic deficits after surgical treatment for epidural abscess in the thoracic or lumbar spine

BACKGROUND CONTEXT

Spinal epidural abscess (SEA) can cause neurologic deficits and needs urgent surgical intervention. Many clinical factors had been proposed to predict surgical outcomes in patients with SEA, but the predictive radiographic risk factors for residual neurologic deficits were not addressed sufficiently.

PURPOSE

To analyze the clinical and radiographic risk factors for residual neurologic deficit in patients with SEA after surgical intervention of the thoracic or lumbar spine.

STUDY DESIGN/SETTING

A retrospective consecutive case series.

PATIENT SAMPLE

From January 2005 through December 2014, 53 patients with primary SEA, confirmed by culture or histopathology, in the thoracic or lumbar spine who underwent posterior-only approach surgery at our hospital.

OUTCOME MEASURES

Neurologic status was assessed using the Frankel grading system preoperatively, postoperatively, and at final follow-up.

METHODS

The patients were allocated into two groups based on the presence of postoperative residual neurologic deficits. Patients' demographic, clinical, and factors based on magnetic resonance imaging (MRI) were analyzed for their influence on residual neurologic deficits. Clinical factors included age, sex, diabetes, comorbidities, pathogens, affected spinal levels, the interval between onset of symptoms to surgery, preoperative neurologic status, presence of cauda equina syndrome, and surgical procedures. MRI factors included the distribution of abscesses within the spinal canal, presence of ring enhancement, presence of paravertebral abscess or psoas abscess, canal compromise anteroposterior (AP) ratio and cross-sectional area ratio, abscess length, and abscess thickness.

RESULTS

Thirty-five of the 53 patients (66%) had preoperative neurologic deficits, and 21 of 53 patients (40%) had postoperative residual neurologic deficits. Patients' neurologic status improved significantly after the surgery (p<.001). Risk factors including age, diabetes, cauda equina syndrome, presence of anterior with posterior (A+P) dural abscess, canal compromise AP ratio, cross-sectional area ratio, abscess length, and abscess thickness were significantly correlated with postoperative residual neurologic deficits. In multivariate logistic regression analysis, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the four most significant factors related to residual neurologic deficits.

CONCLUSIONS

In patients with SEA of the thoracic and lumbar spine, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the most significant preoperative risk factors for residual neurologic deficits after surgery.

Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications

Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.

Pyogenic Spondylitis: Clinical Features, Diagnosis and Treatment

Although pyogenic spondylitis is an infrequent infection, its incidence is increasing because of the growing number of elderly people and immunocompromised patients. Diagnosis is often difficult and appropriate imaging, blood cultures and/or biopsy are essential in making an early diagnosis. Most of the cases can be treated non-operatively. Surgical treatment is indicated in patients with spinal cord or cauda equine compression with progressive neurological deficits and/or patients who have failed conservative treatment. Early and accurate diagnosis of pyogenic spondylitis is important for timely and effective management, in order to reduce the occurrence of spinal deformity and dysfunction.

Treatment of a Staphylococcus lugdunensis cervical epidural abscess

First reported in 1988, Staphylococcus lugdunensis is a virulent coagulase-negative Staphylococcus species often associated with endocarditis. This is the first case report describing this infection in the cervical spine. A 58-year-old, left-handed Caucasian woman with no significant medical history presented with neck and left arm pain. Neurological examination revealed mild left deltoid 4/5 weakness and myelopathy. She was found to have an epidural cervical spinal cord mass that was causing severe cord compression and underwent partial anterior cervical decompression of the mass. On entering what was believed to be the mass, yellow-tinged fluid was encountered. An abscess was immediately suspected, so the dura was not entered. The specimen sent for culture was identified a day later as S. lugdunensis A two-dimensional echocardiogram was negative for vegetations. A peripherally inserted central catheter line was placed and the patient discharged on 6 weeks of physical therapy and 6-8 weeks of intravenous cefazolin.

Neurological Outcomes After Surgical or Conservative Management of Spontaneous Spinal Epidural Abscesses: A Systematic Review and Meta-Analysis of Data From 1980 Through 2016

STUDY DESIGN

This is a meta-analysis.

OBJECTIVE

Perform a systematic review and quantitative meta-analysis of neurological outcomes from all available spinal epidural abscess (SEA) literature published between 1980 and 2016.

SUMMARY OF BACKGROUND DATA

Current literature on SEAs lacks large-scale data characterizing prognostic factors and surgical indications.

MATERIALS AND METHODS

PubMed was queried for studies reporting neurological outcomes from patients undergoing conservative or surgical management for spontaneous SEA. Inclusion criteria included outcomes data measured ≥6 months after presentation, ≥10 human subjects, and diagnosis by magnetic resonance imaging or Computed tomography-myelogram. Where available, demographic data, abscess location, comorbidities, pretreatment neurological deficits, treatment methods, bacterial speciation, and complications were extracted from each study. Potential outcome predictors represented by continuous variables were compared using student t test and categorical variables were compared using the Pearson χ test. Variables identified as potentially associated with outcome (P≤0.05) were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

In total, 808 patients were analyzed from 20 studies that met inclusion criteria. 456 (56.3%) patients were treated with surgery and antibiotics, and 353 (43.7%) patients were managed with antibiotics alone. Neither surgical intervention (OR=1.01, 95% CI=0.40-2.59), lumbosacral location (OR=1.51, 95% CI=0.23-9.79), nor neurological deficit on presentation (OR=0.88, 95% CI=0.40-1.92) were significantly associated with good (stable or improved) or bad (worsened) neurological outcome, whereas delayed surgery was significantly associated with bad outcome (OR=0.01, 95% CI=0.02-0.62) and cervicothoracic location approached significance for predicting bad outcome (OR=0.41, 95% CI=0.15-1.09).

CONCLUSIONS

Current literature does not definitively support or oppose surgical intervention in all SEA cases. Therefore, until better evidence exists, the decision to operate must be made on an individual case-by-case basis with the goals of preventing neurological decline, obtaining source control after failed conservative treatment, or restoring spinal stability.

Lumbar Epidural Abscesses: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Spinal epidural abscesses (SEAs) are rare, but when missed or when diagnosis is delayed, SEA can lead to permanent neurological impairment or death. Limited information exists on the optimal treatment modalities for SEA, especially in the lumbar spine. We synthesize the current literature to identify the clinical features, diagnosis, management, and outcomes of lumbar SEA.

METHODS

Queries in 4 databases-EMBASE, MEDLINE, Scopus, and Web of Science-were performed using comprehensive search terms to locate published literature on lumbar SEA.

RESULTS

Ten articles reporting results for 600 cases of lumbar SEA were included, published between 2000 and 2017. Negative prognostic factors included diabetes, older age, methicillin-resistant Staphylococcus aureus, immune compromise, and more severe disease at presentation. Early first-line surgically treated patients responded better, specifically in terms of motor recovery, than those undergoing medical management or failing medical treatment, despite generally worse initial presentation. Elevated C-reactive protein, leukocytosis, and positive blood cultures predicted medical management failure.

CONCLUSIONS

This systematic review provides guidance to neurological and orthopedic spine surgeons seeking the best treatment for lumbar-localized SEA. This study is limited by a dearth of high-quality publications to support evidenced-based management recommendations. Surgical treatment appears to provide better outcomes than medical treatment alone, especially in those who present with a motor deficit. Further investigation is needed to confirm this finding. What is clear is that early recognition and treatment remains crucial to minimizing morbidity and mortality of SEA.

Clinical outcomes of percutaneous suction aspiration and drainage for the treatment of infective spondylodiscitis with paravertebral or epidural abscess

BACKGROUND CONTEXT

Patients with infective spondylodiscitis who failed conservative treatment are generally indicated for open surgery. However, some patients are poor candidates for standard surgery, hence the need to evaluate less invasive approaches. Good outcomes were previously reported for percutaneous suction aspiration and drainage (PSAD) in the treatment of infective spondylodiscitis resistant to conservative therapy. We recently extended the surgical approach of PSAD to allow drainage of paravertebral or epidural abscesses in patients with progressive infective spondylodiscitis.

PURPOSE

To evaluate the clinical outcomes of PSAD for infective spondylodiscitis with paravertebral or epidural abscess.

DESIGN

Retrospective case series.

PATIENT SAMPLE

Patients with infective spondylodiscitis and associated epidural or paravertebral abscess treated using PSAD at our institution, between 1998 and 2014.

OUTCOME MEASURES

Serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and imaging data obtained via plain radiography, computed tomography, and magnetic resonance imaging were analyzed. Serum measurements were taken preoperatively and at several time points postoperatively. Clinical outcomes were evaluated using the modified MacNab criteria for overall functional mobility.

METHODS

Data were obtained from the patients' case notes, radiological images, and medical records. Student t test was used to assess the relevance of changes in serum levels of CRP and ESR at each evaluated time point, as well as the change in sagittal Cobb angle between the preoperative state and the state at final follow-up.

RESULTS

Fifty-two patients (31 men and 21 women; average age, 70.6 years) were included in our analysis. The median (range) CRP levels and ESR values at the time of diagnosis were 6.86 (0.04-20.15) mg/dL and 78.8 (26-120) mm/h, respectively. At 1 year postoperatively, these values had decreased to 0.18 (0.0-1.2) mg/dL and 13.8 (4-28) mm/h for CRP and ESR, respectively. At final follow-up, bone union was observed in 80.8% (42 of 52) of patients, with instability identified in five patients. Regarding functional mobility, excellent outcomes were obtained in 26.9% (14 of 52) of patients, whereas good, fair, and poor outcomes were noted in 42.3% (22 of 52), 3.9% (2 of 52), and 26.9% (14 of 52) of patients, respectively. Overall, treatment was considered effective in 69.2% (36 of 52) of patients.

CONCLUSIONS

Percutaneous suction aspiration and drainage can serve as an effective alternative to open surgery for the treatment of patients with progressive infective spondylodiscitis and associated paravertebral or epidural abscess.

Predictors of conservative treatment for pyogenic spondylitis

Introduction

Although initial treatments for pyogenic spondylitis include conservative approaches such as rest and antibiotics, some cases are refractory to conservative therapy. The objective of this study was to clarify the predictors for achievement of C-reactive protein (CRP) normalization in pyogenic spondylitis by conservative therapy.

Methods

In the present study, we enrolled 83 patients (51 men and 32 women) with conservatively treated pyogenic spondylitis from 2006 to 2015. Multiple logistic regression analysis was used to examine the association of achievement of CRP normalization with the number of infected vertebrae, bacterial strain, blood data, and the expansion of abscess to the epidural space by using functional magnetic resonance imaging.

Results

We found significant differences in the subjects with and without achievement of CRP normalization with respect to age, the number of affected vertebrae, ratio of resistant pathogenic bacteria, ratio of expansion of abscess to the epidural space, and blood data such as Hb, ALB, eGFR, Cr, and ALP levels.

After adjustment for age and sex, the number of infected vertebral bodies, resistant bacteria, expansion of abscess to the epidural space, and Hb level showed significant associations with the normalization of CRP. In addition, we used multiple logistic regression analysis with age, sex, number of infected vertebral bodies, resistant bacteria, expansion of abscess to the epidural space, and serum Hb level as explanatory variables. We found that expansion of the abscess to the epidural and paravertebral spaces was significantly associated with the normalization of CRP level.

Conclusions

The number of infected vertebral bodies, resistant strains of pathogenic bacteria, expansion of abscess to the epidural and paravertebral spaces, and serum Hb level predicts the prognosis of patients with pyogenic spondylitis. Particularly, expansion of abscess to the epidural and paravertebral spaces was strongly associated with the achievement of CRP normalization.

Is There an Association Between Magnetic Resonance Imaging and Neurological Signs in Patients With Vertebral Osteomyelitis?: A Retrospective Observational Study on 121 Patients

Neurological complications can occur in up to 51% of vertebral osteomyelitis (VO) in surgical series. The aim of our study was to estimate the frequency of neurological signs in a nonselected population of patients with VO and to assess clinical and MRI changes associated with these complications.We reviewed medical charts of patients with VO from 2007 to 2014 in our University Hospital and their MRIs were analyzed by a radiologist blinded from clinical data. Neurological status was defined as follow: normal, minor signs (radiculalgia or sensory loss), and major signs (motor deficit and/or sphincter dysfunction).A total of 121 patients were included. Mean age was 64.3 years. Overall, 50 patients (40%) had neurological signs, 26 were major signs (21.5%). Neurological signs were present at the time of admission in 37 patients and happened secondarily in 13 cases. MRI changes associated with major neurological signs were: Cervical involvement (P = 0.011), dural sac compression (P = 0.0012), ventral effacement of the subarachnoidal space (P < 0.001), compressive myelopathy (P = 0.006). More than 50% of the vertebral body destruction (P = 0.017), angular kyphosis (P = 0.016) partial or complete destruction of posterior arch (P = 0.032) were also associated with these signs. Neither epidural abscesses, multifocal lesions, loss of disk height, nor nerve roots compression were associated with major neurological signs.Neurological signs occurred in 40% of our patients with one half being major signs. Cervical involvement, vertebral destruction, angular kyphosis, dural compression, effacement of subarachnoid space and compressive myelopathy on MRI were risk factors associated with neurological complications.

Primary pyogenic spinal epidural abscess: How late is too late and how bad is too bad? - A study on surgical outcome after delayed presentation

Spinal epidural abscess is a rare clinical entity with considerable morbidity. Even with prompt diagnosis and treatment, many patients are left with persistent residual neurological deficits. The present study details the outcome in 23 patients of primary pyogenic spinal epidural abscess, addressing the outcome following late presentation at a neurological facility. At presentation only 2 patients had relatively preserved neurological status. Eleven patients were paraplegic. All the patients underwent laminectomy and evacuation of abscess. A good functional outcome was observed in almost half of the patients, and there was a significant reduction in the number of the patients with severe disability. Factors influencing the outcome are described in this study.

The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm

OBJECT

Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery.

METHODS

A PubMed database search was performed using a combination of search terms and Medical Subject Headings, to identify clinical studies reporting on the treatment and outcome of SEA.

RESULTS

The literature review revealed 28 original case series containing at least 30 patients and reporting on treatment and outcome. All cohorts were deemed Class III evidence, and in all but two the data were obtained retrospectively. Based on the conclusions of these studies along with selected smaller studies and review articles, the authors present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management.

CONCLUSIONS

Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.

Surgical treatment of patients with spondylodiscitis and neurological deficits caused by spinal epidural abscess (SEA) is a predictor of clinical outcome

STUDY DESIGN

Retrospective study.

OBJECTIVE

The purpose of this study was to investigate the question whether surgical treatment of patients with spondylodiscitis and neurological deficits caused by a spinal epidural abscess (SEA) is a predictor of clinical outcome.

SUMMARY OF BACKGROUND DATA

Spondylodiscitis with an accompanying SEA is a serious medical condition that is associated with potentially high risk for long-term neurological morbidity. In the literature, up to 75% of patients suffer from neurological deficits related to SEA in spondylodiscitis. Independent of treatment, residual neurology persists at a high rate.

METHODS

A retrospective analysis of 135 patients admitted to our department due to a diagnosis of spondylodiscitis was performed. Presence of SEA was evaluated based on computed tomography and magnetic resonance imaging. Neurological status was documented on admission and at discharge according to the Frankel Score. In addition, our patient population was separated into group I without neurological deficits (Frankel E) and group II with abnormal Frankel A-D. Surgical and nonsurgical therapy was retrospectively evaluated. Data were statistically analyzed using the 2-sided Fisher exact test.

RESULTS

On admission, 102 patients were graded as Frankel E in group I. In group II, 15 were Frankel D, 8 Frankel C, 8 Frankel B, and 2 Frankel A. After treatment, 105 patients were Frankel E, 19 Frankel D, 4 Frankel C, 3 Frankel B, and none Frankel A. Four patients died because of severe comorbidities. In group II, 13 of 33 patients had a SEA. Twelve patients showed improvement in Frankel grade, 1 remained unchanged. Of the 20 patients in group II without a SEA, 11 improved and 9 remained unchanged. Twenty-eight of the 33 patients in group II were treated surgically. Patients in both groups with improved neurology showed an upgrade by 1 or 2 Frankel scores. There was no deterioration of neurology. The correlation between surgically treated patients with SEA in comparison with patients without SEA is considered to be statistically significant.

CONCLUSION

Surgical treatment of patients with spondylodiscitis and neurological deficits caused by SEA is a predictor of clinical outcome.

Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections

The incidence of spinal infections has increased in the past two decades, owing to the increasing number of elderly patients, immunocompromised conditions, spinal surgery and instrumentation, vascular access and intravenous drug use. Conventional MRI is the gold standard for diagnostic imaging; however, there are still a significant number of misdiagnosed cases. Diffusion-weighted imaging (DWI) with a b-value of 1000 and apparent diffusion coefficient (ADC) maps provide early and accurate detection of abscess and pus collection. Pyogenic infections are classified into four types of extension based on MRI and DWI findings: (1) epidural/paraspinal abscess with spondylodiscitis, (2) epidural/paraspinal abscess with facet joint infection, (3) epidural/paraspinal abscess without concomitant spondylodiscitis or facet joint infection and (4) intradural abscess (subdural abscess, purulent meningitis and spinal cord abscess). DWI easily detects abscesses and demonstrates the extension, multiplicity and remote disseminated infection. DWI is often a key image in the differential diagnosis. Important differential diagnoses include epidural, subdural or subarachnoid haemorrhage, cerebrospinal fluid leak, disc herniation, synovial cyst, granulation tissue, intra- or extradural tumour and post-surgical fluid collections. DWI and the ADC values are affected by susceptibility artefacts, incomplete fat suppression and volume-averaging artefacts. Recognition of artefacts is essential when interpreting DWI of spinal and paraspinal infections. DWI is not only useful for the diagnosis but also for the treatment planning of pyogenic and non-pyogenic spinal infections.

Spondylodiscitis in the elderly patient: clinical mid-term results and quality of life

INTRODUCTION

Focusing on spondylodiscitis in elderly patients current literature does not contain much information.

METHOD

We performed a retrospective case series (n = 32) comparing conservative (group 1; n = 16) versus operative (group 2; n = 16) treated spondylodiscitis patients aged > or =65 years (mean age 74.9 years) from January 2002 to April 2004. The review of the medical records provided information about the pre-hospital time, the inpatient course and the time after discharge. At follow-up (FU) (mean 3.6 years) disease specific and general quality of life (QOL) questionnaires (COMI back patient self-assessment, ODI and SF-36) were administered.

RESULTS

Altogether, 71.9% of the patients could be contacted; 12.5% had died since hospitalisation and 15.6% could not be contacted anymore. At FU based on the visual analogue scale, patients indicated an average of 3.2 for back pain and 2.5 for leg pain. ODI scoring yielded minimal disability for 38.9%, a moderate disability for 22.2%, a severe disability for 22.2% and for 11.1% a crippled situation; 5.6% were bed-ridden or exaggerated their symptoms. The SF-36 PCS amounted to an average of 38.2, the MCS 50.6. Owing to additional surgery-associated risks, operative treatment of spondylodiscitis feature a complication rate twice as high in the respective group, but general complications do not differ. At FU, no statistically remarkable difference concerning QOL and remaining pain became evident between the groups, the operated patients being more satisfied with regard to the treatment of spondylodiscitis.

CONCLUSION

Ultimately, if surgery is indicated the operative risks should be borne in mind, but advanced age should not be the crucial factor in decision-making.