A case ascertainment study of septic discitis: clinical, microbiological and radiological features

Imaging of Spondylodiscitis: A Comprehensive Updated Review-Multimodality Imaging Findings, Differential Diagnosis, and Specific Microorganisms Detection

Spondylodiscitis is defined by infectious conditions involving the vertebral column. The incidence of the disease has constantly increased over the last decades. Imaging plays a key role in each phase of the disease. Indeed, radiological tools are fundamental in (i) the initial diagnostic recognition of spondylodiscitis, (ii) the differentiation against inflammatory, degenerative, or calcific etiologies, (iii) the disease staging, as well as (iv) to provide clues to orient towards the microorganisms involved. This latter aim can be achieved with a mini-invasive procedure (e.g., CT-guided biopsy) or can be non-invasively supposed by the analysis of the CT, positron emission tomography (PET) CT, or MRI features displayed. Hence, this comprehensive review aims to summarize all the multimodality imaging features of spondylodiscitis. This, with the goal of serving as a reference for Physicians (infectious disease specialists, spine surgeons, radiologists) involved in the care of these patients. Nonetheless, this review article may offer starting points for future research articles.

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.

Two-Stage Cervical and Thoracic-Lumbar-Sacral Circumferential Fixation for Pyogenic Spondylitis: A Case Report

Pyogenic spondylitis is a rare life-threatening condition. Conservative treatment with antibiotics is indicated; however, surgery can be considered in refractory cases. The surgical strategy varies, as pyogenic spondylosis can occur from the cervical to sacral regions. To our knowledge, although there is less invasiveness as an advantage in the following management, cervical and thoracic-lumbar-sacral circumferential fixations in two sessions for pyogenic spondylitis have not been previously described. An 84-year-old man complained of ambulation disturbances and pain in the neck and upper and lower extremities (the Japan Orthopaedic Association cervical myelopathy evaluation questionnaire score of 5/17). Magnetic resonance imaging revealed pyogenic spondylitis of the cervical, thoracic, and lumbar regions. Epidural abscesses and spondylodiscitis were concurrently diagnosed with multi-level skipping lesions from the cervical to the sacral regions. As these lesions were resistant to antibiotic treatment and the neurological symptoms worsened, surgical treatment was planned. Anterior cervical discectomy and fusion, and posterior cervical fixation were followed by oblique and posterior lumbar intervertebral fusions with long-level fixation from T12 to the ilium using percutaneous pedicle screws. The surgeries were performed in two sessions to avoid the invasiveness of surgeries in a single session. The patient's condition improved after a second surgery. The patient was discharged on postoperative day 116. No recurrence was observed for six months, and the patient was able to ambulate independently. Two-stage cervical and thoracic-lumbar-sacral circumferential fixation for pyogenic spondylitis contributed to a favorable outcome (the Japan Orthopaedic Association cervical myelopathy evaluation questionnaire score of 13/17).

Dental Infection Causing Methicillin-Resistant Staphylococcus aureus Bacteremia and Spinal Infection: A Case Report

Poor dentition as a source of infection causing bacteremia and spinal infections (such as paraspinal abscess, and discitis) should be considered even in the absence of recent dental surgery. The case presents a patient found to have an infection in the cervical and thoracic spine, methicillin-resistant Staphylococcus aureus bacteremia, and poor dentition. Although the patient had a history of drug use, he denied a history of intravenous drug use. He had Crohn's disease that resulted in periodontal and endodontal tooth disease. The patient was found to have poor dentition with erythematous gums. He had not been to the dentist in over 24 years and had active dental caries. Since he presented with bacteremia and a spinal infection, it is likely the patient had an infection in the oral cavity that spread hematogenously to the blood, and then the spine. This report highlights the importance of considering tooth infections as the source of bacteremia and spinal infections.

The Human Microbiome and Its Role in Musculoskeletal Disorders

Musculoskeletal diseases (MSDs) are characterized as injuries and illnesses that affect the musculoskeletal system. MSDs affect every population worldwide and are associated with substantial global burden. Variations in the makeup of the gut microbiota may be related to chronic MSDs. There is growing interest in exploring potential connections between chronic MSDs and variations in the composition of gut microbiota. The human microbiota is a complex community consisting of viruses, archaea, bacteria, and eukaryotes, both inside and outside of the human body. These microorganisms play crucial roles in influencing human physiology, impacting metabolic and immunological systems in health and disease. Different body areas host specific types of microorganisms, with facultative anaerobes dominating the gastrointestinal tract (able to thrive with or without oxygen), while strict aerobes prevail in the nasal cavity, respiratory tract, and skin surfaces (requiring oxygen for development). Together with the immune system, these bacteria have coevolved throughout time, forming complex biological relationships. Changes in the microbial ecology of the gut may have a big impact on health and can help illnesses develop. These changes are frequently impacted by lifestyle choices and underlying medical disorders. The potential for safety, expenses, and efficacy of microbiota-based medicines, even with occasional delivery, has attracted interest. They are, therefore, a desirable candidate for treating MSDs that are chronic and that may have variable progression patterns. As such, the following is a narrative review to address the role of the human microbiome as it relates to MSDs.

Increasing incidence of spondylodiscitis in England: An analysis of the national health service (NHS) hospital episode statistics from 2012 to 2021

Background

Spondylodiscitis is a potentially life-threatening infection of the intervertebral disk and adjacent vertebral bodies, with a mortality rate of 2-20%. Given the aging population, the increase in immunosuppression, and intravenous drug use in England, the incidence of spondylodiscitis is postulated to be increasing; however, the exact epidemiological trend in England remains unknown.

Objective

The Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise the annual activity and longitudinal change of spondylodiscitis in England.

Methods

The HES database was interrogated for all cases of spondylodiscitis between 2012 and 2019. Data for the length of stay, waiting time, age-stratified admissions, and 'Finished Consultant Episodes' (FCEs), which correspond to a patient's hospital care under a lead clinician, were analysed.

Results

In total, 43135 FCEs for spondylodiscitis were identified between 2012 and 2022, of which 97.1% were adults. Overall admissions for spondylodiscitis have risen from 3 per 100,000 population in 2012/13 to 4.4 per 100,000 population in 2020/21. Similarly, FCEs have increased from 5.8 to 10.3 per 100,000 population, in 2012-2013 and 2020/21 respectively. The highest increase in admissions from 2012 to 2021 was recorded for those aged 70-74 (117% increase) and aged 75-59 (133% increase), among those of working age for those aged 60-64 years (91% increase).

Conclusion

Population-adjusted admissions for spondylodiscitis in England have risen by 44% between 2012 and 2021. Healthcare policymakers and providers must acknowledge the increasing burden of spondylodiscitis and make spondylodiscitis a research priority.

Spondylodiscitis-a cohort analysis of its identification and management

PURPOSE

Discitis represents infection of the intervertebral disc and osteomyelitis of the adjacent end plates. Classically, patients present with fever and back pain. Varied presentations and lack of adherence to guidelines lead to great variation in its identification and management. The primary objective of this study was to conduct a cohort analysis, assessing the identification and management of discitis, in a busy secondary orthopaedic centre.

METHODS

A retrospective study was conducted, of cases diagnosed and treated for discitis, in a secondary orthopaedic department, within the UK from January 2017 to October 2019. During this time period, all patients who underwent magnetic resonance imaging (MRI) spine were identified. Patients with MRI-proven discitis were then added into the study.

RESULTS

A total of 152 MRIs showed radiographic features of discitis. Of these, only 38 had a clear clinical correlation. Back pain was the most common presenting complaint followed by fever. The commonest site of involvement was vertebral levels L5 and S1. All patients had baseline bloods, and most, but not all, had blood cultures taken. Staphylococcus aureus was the most frequently isolated, causative organism. The mainstay of treatment was intravenous flucloxacillin, with most patients requiring a minimum of six weeks.

CONCLUSION

Our study has helped define the population of patients presenting with discitis, in a busy secondary orthopedic center. Analyzing over two years of data has provided us with valuable insight into the most appropriate diagnostics and management for discitis.

Imaging of Spondylodiscitis: An Update

Spondylodiscitis is an infection of the vertebral body and/or intervertebral disc, which can also involve the epidural space, posterior elements, and paraspinal soft tissues. Due to high morbidity and mortality, prompt diagnosis and treatment of spondylodiscitis is critical. However, diagnosis can be challenging due to nonspecific signs and symptoms. Magnetic resonance imaging with and without contrast is the imaging modality of choice due to high sensitivity and specificity. Intravenous administration of gadolinium contrast can better demonstrate the extent of soft tissue and bone abscesses. However, magnetic resonance imaging is less useful in the evaluation of treatment response. When magnetic resonance imaging cannot be performed or is not diagnostic, radionuclide imaging is a useful alternative. Although bone scintigraphy frequently is used as a screening test, false negative results can occur early in the course of the infection and in the elderly. This test is not useful for detecting the soft tissue infections that often accompany or mimic spondylodiscitis. Gallium-67 citrate improves the specificity of the bone scan, can detect infection earlier than the bone scan, may be more sensitive, especially in elderly patients, and identifies accompanying soft tissue infection. Performing SPECT and SPECT/CT improve accuracy. The 2-3 day delay between radiopharmaceutical administration, poor image quality, and relatively high patient radiation dose are significant disadvantages of gallium-67. Furthermore gallium-67 is no longer as readily available as it once was. ¹⁸F-FDG imaging is the radionuclide test of choice for spondylodiscitis. The procedure, completed in one day, is sensitive, has a high negative predictive value, and reliably differentiates degenerative from infectious vertebral body end-plate abnormalities. ¹⁸F-FDG has outperformed bone and gallium-67 imaging in comparative studies. ¹⁸F-FDG may be able to provide an objective means for monitoring response to treatment. The potential of other agents for diagnosing spondylodiscitis has been studied. Although indium-111biotin accurately diagnoses spondylodiscitis, this radiopharmaceutical has never been commercially available. Gallium-68 citrate and ^99mTc-radiolabeled antimicrobial peptides have been investigated, but their role in the diagnosis of spondylodiscitis has not been established. Labeled leukocyte scintigraphy has no role in the diagnosis of spondylodiscitis.

Complications, Length of Hospital Stay, and Cost of Care after Surgery for Pyogenic Spondylodiscitis

BACKGROUND

 Infectious Spondylodiscitis is a heterogeneous disease usually affecting a fragile patient population with multiple comorbidities. Therefore, surgical and medical complications are important considerations before initiating treatment.

METHODS

 This retrospective analysis included data of 218 patients who underwent surgical treatment for pyogenic Spondylodiscitis between 2008 and 2016. Groups were divided into length of hospital stay (LOS) (group I ≤21 days and group II>21 days). Analysis included patient age, gender, Charlson comorbidity index, smoking, obesity, osteoporosis, colonization with multidrug-resistant bacteria, preoperative neurologic deficit, pre- and postoperative inflammation markers (CRP and WBC), duration of surgery, number of operated segments, vertebrectomy, and postoperative medical and surgical complications. The case value for each patient expressed in Euro was retrieved from hospital records and included in the analysis.

RESULTS

 Duration of stay after surgical treatment of Spondylodiscitis was ≤21 days (range: 4-21 days; mean: 16 days) in 41% of patients and >21 days (range: 22-162 days; mean: 41 days) in 59% of the patients. Multivariate analysis showed that both medical complications (odds ratio [OR]: 2.62; 95% confidence interval [CI]: 1.24-5.56; p=0.012) and surgical site infection (OR: 6.04; 95% CI: 2.35-15.51; p<0.001) were independently associated with a long hospital stay. Case values averaged at €21,667±1,579 (minimum: €2,888; maximum: €203,802) and correlated significantly with the length of hospital stay (Pearson's correlation coefficient: 0.681; p<0.05). The occurrence of a postoperative complication increased the cost of care significantly from €17,790 to 24,527 on average (p=0.025).

CONCLUSIONS

 This study provides benchmark data for patients treated surgically for Spondylodiscitis. Surgical site infection and medical complications are the main drivers of prolonged hospital stays and cost of care.

Is There a Difference in Clinical Features, Microbiological Epidemiology and Effective Empiric Antimicrobial Therapy Comparing Healthcare-Associated and Community-Acquired Vertebral Osteomyelitis?

Background: Empiric antibiotic therapy for suspected vertebral osteomyelitis (VO) should be initiated immediately in severely ill patients, and might be necessary for culture-negative VO. The current study aimed to identify differences between community-acquired (CA) and healthcare-associated (HA) VO in terms of clinical presentation, causative pathogens, and antibiotic susceptibility. Methods: Cases of adult patients with VO treated at a German university orthopaedic trauma center between 2000 and 2020 were retrospectively reviewed. Patient history was used to distinguish between CA and HA VO. Susceptibility of antibiotic regimens was assessed based on antibiograms of the isolated pathogens. Results: A total of 155 patients (with a male to female ratio of 1.3; and a mean age of 66.1 ± 12.4 years) with VO were identified. In 74 (47.7%) patients, infections were deemed healthcare-associated. The most frequently identified pathogens were Staphylococcus aureus (HAVO: 51.2%; CAVO: 46.8%), and Coagulase-negative Staphylococci (CoNS, HAVO: 31.7%; CAVO: 21.3%). Antibiograms of 45 patients (HAVO: n = 22; CAVO: n = 23) were evaluated. Significantly more methicillin-resistant isolates, mainly CoNS, were found in the HAVO cohort (27.3%). The highest rate of resistance was found for cefazolin (HAVO: 45.5%; CAVO: 26.1%). Significantly higher rates of resistances were seen in the HAVO cohort for mono-therapies with meropenem (36.4%), piperacillin–tazobactam (31.8%), ceftriaxone (27.3%), and co-amoxiclav (31.8%). The broadest antimicrobial coverage was achieved with either a combination of piperacillin–tazobactam + vancomycin (CAVO: 100.0%; HAVO: 90.9%) or meropenem + vancomycin (CAVO: 100.0%; HAVO: 95.5%). Conclusion: Healthcare association is common in VO. The susceptibility pattern of underlying pathogens differs from CAVO. When choosing an empiric antibiotic, combination therapy must be considered.

Pyogenic psoas abscess on the dorsal side, and bacterial meningitis and spinal epidural abscess on the ventral side, both of which were induced by spontaneous discitis in a patient with diabetes mellitus: A case report

Type 2 diabetes mellitus patients are immunocompromised, particularly under poorly controlled conditions, and thereby they could develop rare inflammatory diseases, such as spontaneous discitis, pyogenic psoas abscess, spinal epidural abscess and bacterial meningitis. Herein we report a pyogenic psoas abscess on the dorsal side, and bacterial meningitis and spinal epidural abscess on the ventral side, both of which were induced by spontaneous discitis in a patient with poorly controlled type 2 diabetes mellitus. This case was very rare and interesting, because we successfully treated various infections with antibiotics over a long period of time, complicated by hyperglycemic crises, although the patient suffered severe bone destruction and required rehabilitation for a long time.

Thoracic pyogenic infectious spondylitis presented as pneumothorax: A case report

BACKGROUND

Pyogenic infectious spondylitis (PIS) is a rare condition, with an incidence between 0.2 and 2 cases per 100000 per annum. It’s most common symptom—back or neck pain—occurs in more than 90% of cases. Herein, we reported a case of thoracic PIS accompanied by pneumothorax in a 65-year-old male patient.

CASE SUMMARY

A 65-year-old man presented with right chest pain and dyspnea. The initial erect posteroanterior chest radiography revealed pneumothorax, which was further evaluated by chest computed tomography, revealing pleural effusion in the right lung and a paravertebral abscess with bony destruction of vertebral body. Based on magnetic resonance imaging, the patient was diagnosed with thoracic infectious spondylitis with an anterior paravertebral abscess. He was prescribed antibiotics and underwent neurosurgery due to aggravated symptoms and neurologic deficit. Tissue examination revealed that the cause of pleural effusion and pneumothorax was Staphylococcus aureus infection contiguously spread to lung pleura. After several surgical treatments with intravenous antibiotic therapy for two months and transition to oral antibiotics (rifampin 600 mg qd and ciprofloxacin 500 mg bid), the patient received physical therapy to recover balance. One month after discharge, the patient had no chest pain or dyspnea, and exhibited no elevation in inflammatory markers or new thoracic lesions.

CONCLUSION

To our knowledge, this is the very first report of a case of thoracic PIS with pneumothorax.

Characteristics, Management and Outcomes of Spondylodiscitis in Children: A Systematic Review

Spondylodiscitis (SD) is the concurrent infection of the intervertebral disc and the adjacent vertebral bodies. Currently, there is a substantial lack of structured reviews about this topic. The aim of this study was to systematically review the available literature in order to determine the main features of pediatric SD. A systematic search of MEDLINE database was performed, according to the PRISMA guideline recommendations. Clinical features, laboratory data, radiological signs, treatments strategies, and outcomes were summarized. Studies’ quality assessments were performed using the JBI Critical Appraisal Checklists. A total of 35 retrospective studies were analyzed and 340 children were identified. The most frequently affected age class was 0.5–4 years. The most affected site was the lumbar spine. The most commonly reported symptoms were back pain (37.97%) and refusal to walk/to stand/to sit (49.79%). The most frequently identified pathogen was Staphylococcus aureus (n = 33). The most used antibiotics were third generation cephalosporins. The intravenous therapy duration range was 1–25 weeks, the oral therapy duration range was 5 days–36 months. Surgery was used in 5.88% of children. In 29 cases clinical sequelae were documented. This study provides the main features of pediatric SD; it also emphasizes the significant gaps in the literature regarding this topic.

Alterations in the fecal microbiota of patients with spinal cord injury

Objectives

Spinal cord injury (SCI) is associated with severe autonomic dysfunction. Patients with SCI often suffer from a lack of central nervous system control over the gastrointestinal system. Therefore, we hypothesized that patients with SCI would cause intestinal flora imbalance. We investigated alterations in the fecal microbiome in a group of patients with SCI.

Methods

Microbial communities in the feces of 23 patients and 23 healthy controls were investigated using high-throughput Illumina Miseq sequencing targeting the V3-V4 region of the 16S ribosomal RNA (rRNA) gene. The relative abundances between the fecal microbiota at the genus level in patients with SCI and healthy individuals were determined using cluster analysis.

Results

The structure and quantity of fecal microbiota differed significantly between patients with SCI and healthy controls, but the richness and diversity were not significantly different. A two-dimensional heatmap showed that the relative abundances of forty-five operational taxonomic units (OTUs) were significantly enriched either in SCI or healthy samples. Among these, 18 OTUs were more abundant in healthy controls than in patients with SCI, and 27 OTUs were more abundant in the SCI group than in healthy controls.

Conclusion

Our study showed that patients with SCI exhibited microbiome dysbiosis.

Development and current use of local antibiotic carriers in spondylodiscitis : Pilot study on reduction of duration of systemic treatment

BACKGROUND

The current study situation regarding the duration of systemic antibiotic treatment for spondylodiscitis is inhomogeneous and varies between 4-12 weeks. Due to the many undesirable side effects the aim is to achieve complete healing without recurrence or hematogenous scatter within the shortest possible period of time. The present pilot study investigated whether the additional application of a local antibiotic carrier to the surgically treated intervertebral disc space can contribute to a further reduction of treatment duration.

MATERIAL AND METHODS

In the pilot study 20 patients with acute spondylodiscitis and indications for surgical intervention were included. Surgical treatment was carried out by dorsal instrumentation, radical debridement of the site of infection, and cage interposition in the affected disc space. The remaining disc space was filled with homologous cancellous bone and antibiotic-loaded calcium sulfate hydroxyapatite pellets. A classification into a long-term and a short-term antibiotic group was performed. Both groups initially received a 10-day parenteral antibiotic administration. This was followed by oral antibiotics for 2 or 12 weeks, depending on the group. During the 12-month follow-up inflammation parameters, the local infection situation as well as the bony fusion and antibiotic tolerance were regularly checked.

RESULTS

The average age of the patients was 66.7 ± 11.2 years. Intraoperative detection of pathogens was successful in 65%. In 60% the antibiotic carrier was loaded with gentamicin, in 40% with vancomycin. At follow-up, all patients except one in the short-term antibiotic group had inflammation parameters within the normal range after 3 months. In the long-term antibiosis group, two patients still showed elevated infection values after 3 months, otherwise the values were within the normal range. After 12 months a complete cure of the infection was achieved in all patients. Antibiotic treatment intolerance occurred in 10% of the short-term antibiotic group and in 50% of the long-term group.

CONCLUSION

The results of the present pilot study show that with the additional use of absorbable local antibiotic carriers in the surgical treatment of bacterial spondylodiscitis it is possible to shorten the duration of systemic antibiotic treatment to 3 weeks. This can reduce the side effects and incompatibility of treatment and still achieve similar healing results.

Vague neck pain following a gastrointestinal procedure: a rare case presentation of vertebral osteomyelitis and cervical epidural abscess

INTRODUCTION

Vertebral osteomyelitis (VO), spondylodiscitis, and spinal epidural abscesses (SEA) are infectious and inflammatory processes impacting the spine that cause major morbidity and mortality. They require prolonged hospital stays with expensive treatment regimens. Along with acute management, studies have provided evidence highlighting poor long-term outcomes. VO accounts for ~2% of all osteomyelitis. Recent data have illustrated an increase in incidence to 5.4 per 100,000 person years. The majority of patients that present with SEA and VO typically have some combination of back pain, fevers, and neurological deficits.

CASE PRESENTATION

A 55-year-old woman with known history of hypertension and hyperlipidemia, status-post endoscopic repair of a Zenker's Diverticulum 3 weeks prior, presented to our outpatient clinic with a 2-week history of axial cervical spine pain as well as left sided scapular and deltoid pain. Further questioning and exam revealed no neurologic deficits or fever. As pain persisted and she did not respond to treatment, further imaging was performed. She was found to have cervical discitis, osteomyelitis, and a cervical epidural abscess.

DISCUSSION

Patients presenting with VO/SEA typically have spine pain with some other associated symptoms of spinal cord compression or fevers, making this a rare presentation. The urgency for discovery because of the need for emergent operative intervention is evident by the documented complications associated with a delay in diagnosis. This case report emphasizes the importance of always keeping VO/SEA on the differential for cervical spine pain even with lack of associated symptoms, in order to optimize patient care.

Red flags for the early detection of spinal infection in back pain patients

BACKGROUND

Red flags are signs and symptoms that are possible indicators of serious spinal pathology. There is limited evidence or guidance on how red flags should be used in practice. Due to the lack of robust evidence for many red flags their use has been questioned. The aim was to conduct a systematic review specifically reporting on studies that evaluated the diagnostic accuracy of red flags for Spinal Infection in patients with low back pain.

METHODS

Searches were carried out to identify the literature from inception to March 2019. The databases searched were Medline, CINHAL Plus, Web of Science, Embase, Cochrane, Pedro, OpenGrey and Grey Literature Report. Two reviewers screened article texts, one reviewer extracted data and details of each study, a second reviewer independently checked a random sample of the data extracted.

RESULTS

Forty papers met the eligibility criteria. A total of 2224 cases of spinal infection were identified, of which 1385 (62%) were men and 773 (38%) were women mean age of 55 (± 8) years. In total there were 46 items, 23 determinants and 23 clinical features. Spinal pain (72%) and fever (55%) were the most common clinical features, Diabetes (18%) and IV drug use (9%) were the most occurring determinants. MRI was the most used radiological test and Staphylococcus aureus (27%), Mycobacterium tuberculosis (12%) were the most common microorganisms detected in cases.

CONCLUSION

The current evidence surrounding red flags for spinal infection remains small, it was not possible to assess the diagnostic accuracy of red flags for spinal infection, as such, a descriptive review reporting the characteristics of those presenting with spinal infection was carried out. In our review, spinal infection was common in those who had conditions associated with immunosuppression. Additionally, the most frequently reported clinical feature was the classic triad of spinal pain, fever and neurological dysfunction. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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.

Prevertebral neck abscess with Salmonella sandiego: a case presentation and literature review

We describe an unusual case of a 58-year-old man with type 2 diabetes mellitus (T2DM) developing sepsis secondary to a prevertebral neck abscess. Following cross-sectional imaging, the patient underwent surgical drainage. Salmonella sandiego was isolated from urine, blood and pus cultures. Salmonella species neck infections represent a rare cause of focal salmonellosis, though have been reported in the literature. This is the first reported case of S. sandiego causing neck abscess. The case highlights an atypical presentation of salmonellosis, with the surprising finding of a neck abscess on cross-sectional imaging without evidence of co-existing significant discitis or osteomyelitis.

Postoperative Lumbar Pyogenic Spondylodiscitis: An Institutional Review

Background   Postoperative discitis (POD) remains a dreaded complication in the present era of asepsis. The treatment has been traditionally conservative, but the safety of spinal implants in infective settings has prompted the surgeons to provide rigid immobilization for promoting healing. A major concern in a country like ours is huge patient inflow and long waiting list added to the woe of patient's refusal for a second operative intervention after a first undesirable outcome. Objectives  The aim of the study was to evaluate the functional and radiological outcome of conservative management of POD and determine the methods of prevention. Settings and Design   A retrospective case study series in a tertiary-level hospital. Materials and Methods   Between January 2015 and 2017, 12 cases of POD (10 own and 2 referred) were managed and followed up clinically, radiologically, and with laboratory investigation. Two cases were managed surgically-one with kyphotic deformity and the other with discharging pus. Rest were managed conservatively with analgesics and intravenously followed by oral antibiotics. At 1-year follow-up, patient satisfaction was evaluated using the MacNab outcome assessment. Statistical Analysis   The descriptive data were analyzed mainly by descriptive statistics using mean, median, standard deviation, and interquartile range. Results   Mean follow-up in our series was 15.2 months. Except for two operated cases, we did not go for the invasive procedure for isolation of organism in any of our cases. The total duration of antibiotic in our series was for the mean of 7.3 weeks. Visual analog scale score returned from8 initially to baseline and at final follow-up-4 excellent, 6 good, and 2 had fair outcome. There was no adverse outcome. Conclusions   The majority of POD can be managed conservatively. Surgery is reserved only for special cases. Magnetic resonance imaging is the investigation of choice for diagnosing discitis. Intraoperative use of gentamicin-mixed normal saline wash reduces the incidence of discitis.

SPONDYLODISCITIS INVESTIGATION AND THERAPEUTIC PROTOCOL: NEUROSURGERY SERVICE RESULTS

ABSTRACT Objective: Spondylodiscitis is still a frequent pathology among neurosurgical services, and its correct treatment involves infectious, neurological and orthopedic goals. The authors describe the protocol and report the diagnostic and therapeutic results after its implementation. Methods: A prospective prognostic study (Level I) including patients with primary spondylodiscitis treated in the Neurosurgical Service of Cristo Redentor Hospital from January 2014 to March 2018. Demographic, spine, infectious and treatment-related variables were analyzed. The numerical variables are presented as mean and standard deviation or median and interquartile range (according to their parametricity), and are compared by the student's t-Test or Mann-Whitney U Test, respectively. Results: Thirty seven patients were included. The sexes were evenly distributed, with predominantly Caucasians, and a mean age of 56.89 ±15.33. Hypertension and type 2 diabetes were the most frequent comorbidities. Vertebral lumbar level was the most involved segment. Pathogens were identified in 34 cases (91%), with Staphylococcus aureus being the most prevalent, followed by Koch Bacilli. Inflammatory markers are higher in pyogenic infections at hospital admission, but lower at hospital discharge when compared to tuberculous discitis (p<0.01). Mean hospital stay was higher in the pyogenic group. Conclusion: The protocol described has a high diagnostic level of the pathogen, with cure of infection and satisfactory neurologic outcome in all cases. Level of Evidence I, Diagnostic Studies - Investigating a Diagnostic Test.

Microbicidal Phagocytosis of Nucleus Pulposus Cells Against Staphylococcus aureus via the TLR2/MAPKs Signaling Pathway

Intervertebral disc (IVD) is an immune-privileged organ that lacks immunocytes, such as macrophages or neutrophils; therefore, it is unclear how IVD immunological defense against bacterial infection occurs. Here, we demonstrated that nucleus pulposus cells (NPCs), the vital machinery for maintaining the homeostasis of IVD, exerted microbicidal activity against Staphylococcus aureus via induction of phagolysosome formation. Moreover, we found that the Toll-like receptor 2 (TLR2)/mitogen-activated protein kinases (MAPKs) signaling pathway is critical for bacterial phagocytosis and phagolysosome formation of NPCs. These findings demonstrated for the first time that NPCs could function as non-professional phagocytes against S. aureus infection, thereby enhancing antimicrobial defense against bacterial infections in IVDs.

SponDT (Spondylodiscitis Diagnosis and Treatment): spondylodiscitis scoring system

BACKGROUND

Spondylodiscitis is a chameleon among infectious diseases due to the lack of specific symptoms with which it is associated. It is nevertheless a serious infection, with 7% mortality of hospitalized patients, in large part because of delayed diagnosis. The aim of this study was to develop a diagnosis and course-of-disease index to optimize its treatment.

MATERIAL AND METHODS

Through analysis of 296 patients between January 1998 and December 2013, we developed a scoring system for spondylodiscitis, which we term SponDT (Spondylodiscitis Diagnosis and Treatment) based on three traits: (1) the inflammatory marker C-reactive protein (CRP) (mg/dl), (2) pain according to a numeric rating scale (NRS) and (3) magnetic resonance imaging (MRI), to monitor its progression following treatment.

RESULTS

The number of patients receiving treatment increased over the past 15 years of our study. We also found an increasing age of patients at the point of diagnosis across the study, with an average age of 67.7 years. In 34% of patients, spondylodiscitis developed spontaneously. Almost 70% of them did not receive treatment until the first diagnosis using SponDT. Following treatment against spondylodiscitis, pain intensity decreased from 6.0 to 3.1 NRS. The inflammatory markers also decreased (CRP from 119.2 to 46.7 mg/dl). Similarly, MRI revealed a regression in inflammation following treatment. By employing SponDT, patients were diagnosed and entered into treatment with a score of 5.6 (severe spondylodiscitis) and discharged with a score of 2.4 (light/healed spondylodiscitis).

CONCLUSION

SponDT can be used to support the diagnosis of spondylodiscitis, particularly in patients suffering from back pain and elevated levels of inflammation, and can be used during the course of treatment to optimize control of therapy.

LEVEL OF EVIDENCE

IIa-evidence from at least one well-designed controlled trial which is not randomized.

Spondylodiscitis in end-stage renal disease: a systematic review

OBJECTIVE

Discitis and osteomyelitis are seen in end-stage renal disease (ESRD) patients due to repeated vascular access for hemodialysis and urinary tract infections leading to recurrent bacteremia. Discitis and osteomyelitis are underdiagnosed due to the nonspecific initial presentation of back pain. In this article, we review the literature for better understanding of the problem and the importance of early diagnosis by primary care physicians and nephrologists. In addition, we discuss the decision-making, follow-up, management, and neurological outcomes.

METHODS

A detailed PubMed search was performed using the following terms: "end stage renal disease (ESRD)" and "chronic renal failure (CRF)," combined with "spine infections," "spondylodiscitis," "discitis," and "osteomyelitis." Search results were limited to articles written in English, case reports, and case series from 1973 to 2012. Editorials, reviews, and commentaries were excluded. Only studies involving human patients were included. The authors also included 4 patients from their own patient population.

RESULTS

A total of 30 articles met the inclusion criteria. Including the 4 patients from the authors' patient population, 212 patients with spine infections and maintenance dialysis were identified. The patients' ages ranged from 38 to 78 years. The duration of dialysis ranged from a few days to 16 years. The time from onset of back pain to diagnosis ranged from 3 days to 6 months. The most common causative organism was Staphylococcus aureus, followed by Staphylococcus epidermidis and gram-negative bacteria. Most of the patients were treated with antibiotics alone (76.8%), although surgery was indicated when patients presented with neurological deficits (p < 0.011). Approximately one-quarter of the patients developed neurological deficits, with devastating consequences. Fever and neurological deficits at presentation, culture positive for methicillin-resistant S. aureus, and age > 65 years were highly correlated with mortality in our analysis.

CONCLUSIONS

Several risk factors lead to failure of antibiotics and progression of disease in patients with ESRD. Challenges to diagnosis include vague presenting symptoms, co-existing destructive spondyloarthropathy, poor immune response, chronic elevations of inflammatory markers, and recurrent bacteremia. Infectious processes are more likely to cause permanent neurological deficits than transient deficits. The authors recommend close observation and serial imaging of these patients for early signs of neurological deficits. Any signs of disease progression will require aggressive surgical debridement.

Outcomes of decompression and fusion for treatment of spinal infection

OBJECTIVE

Spine infection including vertebral osteomyelitis, discitis, paraspinal musculoskeletal infection, and spinal abscess refractory to medical management poses significant challenges to the treating physician. Surgical management is often required in patients suffering neurological deficits or spinal deformity with significant pain. To date, best practices have not been elucidated for the optimization of health outcomes and resource utilization in the setting of surgical intervention for spinal infection. The authors conducted the present study to assess the magnitude of reoperation rates in both fusion and nonfusion groups as well as overall health resource utilization following surgical decompression for spine infection.

METHODS

The authors performed an analysis using MarketScan (2001–2015) to identify health outcomes and healthcare utilization metrics of spine infection following surgical intervention with decompression alone or combined with fusion. Adult patients underwent surgical management for primary or secondary spinal infection and were followed up for at least 12 months postoperatively. Assessed outcomes included reoperation, healthcare utilization and payment at the index hospitalization and within 12 months after discharge, postoperative complications, and infection recurrence.

RESULTS

A total of 2662 patients in the database were eligible for inclusion in this study. Rehospitalization for infection was observed in 3.99% of patients who had undergone fusion and in 11.25% of those treated with decompression alone. Reoperation was needed in 12.7% of the patients without fusion and 8.16% of those with fusion. Complications within 30 days were more common in the nonfusion group (24.64%) than in the fusion group (16.49%). Overall postoperative payments after 12 months totaled $33,137 for the nonfusion group and $23,426 for the fusion group.

CONCLUSIONS

In this large cohort study with a 12-month follow-up, the recurrence of infection, reoperation rates, and complications were higher in patients treated with decompression alone than in those treated with decompression plus fusion. These findings along with imaging characteristics, disease severity, extent of bony resection, and the presence of instability may help surgeons decide whether to include fusion at the time of initial surgery. Further studies that control for selection bias in appropriately matched cohorts are necessary to determine the additive benefits of fusion in spinal infection management.

Clinical Characteristics and Outcomes of Patients with Culture-Negative Pyogenic Spondylitis according to Empiric Glycopeptide Use

Background

The optimal choice of antibiotics is challenging in culture-negative pyogenic spondylitis (PS). The empiric use of glycopeptides is suggested depending on various risk factors, although clinical data are sparse. This study aimed to analyze the clinical characteristics and outcomes of patients with culture-negative PS and evaluate the effect of empiric glycopeptide use on clinical outcomes in these patients.

Materials and Methods

Data on the characteristics, treatment, and outcomes of 175 patients diagnosed with PS were retrospectively obtained from the electronic database of a tertiary referral hospital from 2009 to 2016. Patients with negative culture results were grouped by the duration of glycopeptide treatment: glycopeptide therapy <28 days (Group A) and glycopeptide therapy ≥28 days (Group B).

Results

Of 89 patients with negative culture results, 78 were included in the analysis (Group A, n = 66; Group B, n = 12). The mean age of patients with negative culture results was 65.5 years, and 52.6% were male. The median follow-up duration was 573 (interquartile range [IQR], 83 – 1,037) days. The duration of intravenous glycopeptide therapy was 0.0 (IQR, 0.0 – 0.0) days and 55.5 (IQR, 37.0 – 75.7) days for Groups A and B, respectively. Patients who used glycopeptide longer empirically (Group B) had more commonly undergone a previous spinal procedure, including surgery (P = 0.024). The length of hospitalization, erythrocyte sedimentation rate, and C-reactive protein level were significantly higher in Group B compared with those in Group A (P <0.001, P <0.001, and P = 0.006, respectively). Regarding treatment modalities, patients in Group B underwent surgery more frequently (P = 0.017). The duration of parenteral antibiotic treatment was longer in Group B (P <0.001). Recurrence was noted in 7 patients (9.0%), and the recurrence rate was not significantly different between the 2 groups (Group A, 5/66 [7.6%]; Group B, 2/12 [16.7%]; P = 0.293).

Conclusion

The recurrence rate among patients with culture-negative PS was not different based on the duration of empiric glycopeptide use. However, considering the small sample size and heterogeneity of our study population, we suggest that it is reasonable to administer glycopeptide antibiotics in these patients depending on clinical risk factors. Further large-scale prospective studies are needed to obtain more evidence for appropriate antibiotic treatment.

Musculoskeletal Infections in the Emergency Department

Bone and joint infections are potentially limb-threatening or even life-threatening diseases. Emergency physicians must consider infection when evaluating musculoskeletal complaints, as misdiagnosis can have significant consequences. Patients with bone and joint infections can have heterogeneous presentations with nonspecific signs and symptoms. Staphylococcus aureus is the most commonly implicated microorganism. Although diagnosis may be suggested by physical examination, laboratory testing, and imaging, tissue sampling for Gram stain and microbiologic culture is preferable, as pathogen identification and susceptibility testing help optimize long-term antibiotic therapy. A combination of medical and surgical interventions is often necessary to effectively manage these challenging infections.

Management of Postoperative Discitis: A Review of 31 Patients

BACKGROUND

The aim of the study was to retrospectively evaluate the outcome of medical management of postoperative discitis (POD).

MATERIALS AND METHODS

A total of 31 patients treated for POD were included in the study. Clinical, radiological, and laboratory data of all patients were collected and evaluated. All patients were treated initially with bed rest and antibiotic therapy after radiological diagnosis. Surgical management was undertaken after failure of 4 weeks of conservative management. All cases were followed clinically with laboratory and radiological investigations.

RESULTS

Five cases failed to respond to medical management and were treated surgically with debridement and transpedicular fixation. All patients showed clinical recovery till the last follow-up.

CONCLUSION

Early diagnosis and proper management are the keys to successful outcome of postoperative spndylodiscitis. Surgical debridement and fusion are required when conservative treatment fails.

Treatment of lumbar discitis using silicon nitride spinal spacers: A case series and literature review

INTRODUCTION

Septic infection of a lumbar intervertebral disc is a serious disorder which is often difficult to diagnose and appropriately treat because of the rarity of the disease, the varied presentation of symptoms, and the frequency of low-back pain within the overall population. Its etiology can be pyogenic, granulomatous, fungal, or parasitic; its incidence is rising due to increased patient susceptibility and improved diagnostic tools. Conservative treatments involve antibiotics, physical therapy, and/or immobilization. More aggressive management requires discectomy, debridement, and spinal fusion in combination with local and systemic antibiotic administration.

PRESENTATION OF CASES

Presented here are two case studies of lumbar pyogenic discitis associated with Escherichia coli and Candida albicans infections. Both required single-level anterior discectomy followed by spinal fusion using an antimicrobial silicon nitride (Si3N4) spacer for stabilization without instrumentation. Localized antibiotics were used for only one of the patients. Follow-up CT and MRI scans showed that the infections had been resolved with no recurrence of symptoms.

DISCUSSION

Si3N4 is a relatively new spinal spacer material. It was utilized in these two cases because it reportedly provides a local environment which promotes rapid arthrodesis while resisting bacterial adhesion and biofilm formation. It is also highly compatible with X-ray, MRI, and CT imaging modalities. These properties were particularly attractive for these two cases given the patients' histories, presentation of symptoms, and the decision to forego instrumentation.

CONCLUSION

The use of Si3N4 as an antimicrobial spacer may lead to improved outcomes for patients with pyogenic discitis of the lumbar spine.

Imaging of Spondylodiscitis

Spondylodiscitis is an infection of the vertebral body or disc and may also involve the epidural space, posterior elements, and paraspinal soft tissues. It is a cause of morbidity and mortality, and warrants early diagnosis and prompt treatment. Diagnosis can be difficult because of nonspecific signs and symptoms. Magnetic resonance imaging is sensitive and specific and is the imaging modality of choice for spondylodiscitis. Gadolinium contrast can show the extent of soft tissue and bone phlegmon and abscess. The test is less useful for evaluating treatment response. When magnetic resonance imaging cannot be performed or is not diagnostic, radionuclide imaging is a useful alternative. Although bone scintigraphy frequently is used as a screening test, false-negative results can occur, especially in the elderly. This test is not useful for detecting soft tissue infections that accompany or mimic spondylodiscitis. Gallium-67 citrate improves the specificity of the bone scan, can detect infection earlier than the bone scan, may be more sensitive, especially in elderly patients, and identifies accompanying soft tissue infection. Performing SPECT and SPECT/CT improves accuracy. The 2- to 3-day delay between radiopharmaceutical administration and the relatively poor image quality are significant disadvantages of gallium-67. Indium-111 biotin, alone or in combination with streptavidin, accurately diagnoses spondylodiscitis; unfortunately, this agent is not widely available. Currently, ¹⁸F-FDG imaging is the radionuclide test of choice for spondylodiscitis. The procedure, which is completed in a single session, is sensitive, has a high negative predictive value, and reliably differentiates degenerative from infectious vertebral body end plate abnormalities. In comparative investigations, ¹⁸F-FDG has outperformed bone and gallium-67 imaging. Preliminary data suggest that ¹⁸F-FDG may be able to provide an objective means to measure response to treatment. Gallium-68 citrate and 99mTc-radiolabeled antimicrobial peptides have been investigated, but their role in spondylodiscitis has yet to be established.

Retrospective review of CT-guided intervertebral disc biopsies performed at a tertiary referral centre for suspected osteodiscitis

INTRODUCTION

Patients with osteodiscitis are often prescribed antibiotics prior to biopsy. There is controversy in the literature about whether antibiotic pre-treatment prior to CT-guided biopsy decreases the microbiological culture yield. Conclusions from previous studies are influenced by sample size error and selection bias. Our study, conducted in a large number of patients over a 10-year period, clarifies this issue so that best clinical practice is assured.

METHODS

We performed a retrospective audit of the clinical, radiological and microbiological features of adult patients who underwent CT-guided biopsies for suspected osteodiscitis at a tertiary institution. Patients who had received intravenous antibiotic therapy in the month prior to biopsy or oral antibiotics 2 weeks prior to biopsy were considered as having had antecedent treatment.

RESULTS

We initially found no significant difference in the likelihood of a positive culture between patients who had received antecedent treatment and those who had not. However, when we performed a subgroup analysis, we found that using multiple antibiotics influenced the likelihood of a positive culture. A second subgroup analysis demonstrated that pre-treatment reduced the likelihood of a positive culture. This discrepancy arose from the match between the antecedent antibiotics and the organisms' antibiotic sensitivity profile.

CONCLUSION

Antibiotic treatment preceding CT-guided biopsy reduces the likelihood of a positive microbiological culture results. However, due to the often poor match, between the pre-treatment antibiotic and the organisms' antibiotic sensitivity profile, this is often not clinically apparent. Furthermore, positive cultures sensitive to the pre-treatment antibiotics can still be obtained.

Spinal infections in older people: an analysis of demographics, presenting features, microbiology and outcomes

BACKGROUND

Clinical features of infection can become more atypical as we age. Spinal infections can be insidious, and timely diagnosis and treatment are essential to prevent adverse outcomes.

AIMS

To explore differences in presentation and outcomes between younger and older patients with bacterial spinal infections.

METHODS

Clinical, microbiological and radiological information was collected for patients with spinal infections (spondylodiscitis, vertebral osteomyelitis, septic discitis, facet joint septic arthritis and spinal epidural abscess) at a single metropolitan hospital between January 2008 and January 2015. Patients were excluded if they were under 18 years of age or if clinical and imaging findings were inconsistent with the diagnosis. Presenting features, investigations and outcomes were compared for patients ≥65 (older) or <65 (younger) years old.

RESULTS

Of 53 identified patients, 34 (64%) were classified as older, with more males in both older (65%) and younger (79%) groups. Older patients presented later (median symptom duration 13 vs 4 days, P = 0.016). Back pain was nearly ubiquitous. Older patients presented less commonly with fevers (38 vs 63%) and rigors (24 vs 42%) but more commonly with hypotension (18 vs 5%), delirium (24 vs 11%), higher median inflammatory marker levels and variable microbiological findings, although these differences were not statistically significant. They had longer median lengths of stay (24 vs 14 days) and a higher likelihood of death or failure of medical treatment (HR 9.34, P = 0.031). Radicular pain was associated with poor outcome (HR 3.29, P = 0.046).

CONCLUSION

Older patients with spinal infections present later, with higher inflammatory markers and fewer typical infective symptoms and signs; these may contribute to poorer outcomes. A low threshold for promptly investigating older patients with new or worsening back pain should be set.

Incidence, Morbidity, and Surgical Outcomes of Complex Spinal Inflammatory Syndromes in Adults

BACKGROUND

Spondylodiscitis is a rare inflammatory syndrome affecting intervertebral discs and adjacent vertebral bodies. Without appropriate therapy, serious complications, such as secondary spinal epidural abscess (SEA), may prolong recovery time. In this study, we compared the main characteristics of our cohort of patients with spondylodiscitis with those of patients reported in the international literature and analyzed the impact of complications associated with spondylodiscitis on clinical outcomes.

METHODS

We designed a retrospective study based on the database of the National Institute of Clinical Neurosciences, Hungary, between 2008 and 2015. We collected 78 patients suffering from primary spondylodiscitis or primary spinal epidural abscess. Based on the main clinical characteristics of our population (demographic features, initial symptoms, concurrent diseases, laboratory findings, microbiological diagnosis, therapy and clinical outcome) we constructed a database. Odds ratio (OR) counting was used to define the correlation between etiology and stage of recovery.

RESULTS

We found a mild increase in the incidence of spondylodiscitis compared with international standards, and main demographic and clinical characteristics in concordance with international trends. Primary, noncomplicated spondylodiscitis had the best outcome results (OR, 1.25), and complicated spondylodiscitis had the worst, as well as the lowest OR for total recovery (0.6).

CONCLUSIONS

The clinical characteristics of our study cohort did not differ from the international trends. Primary, noncomplicated spondylodiscitis has the highest odds for absolute recovery. Secondary spinal epidural abscess exacerbates ongoing spondylodiscitis, and thus should be considered a poor prognostic factor for spondylodiscitis. Early diagnosis and treatment may prevent serious complications and provide better outcomes.

Pyogenic Vertebral Osteomyelitis: Clinical Features, Diagnosis, and Treatment

Pyogenic vertebral osteomyelitis (PVO) may result in neurological deficits and sequelae, so early diagnosis and appropriate treatment are critical. Many previous studies on PVO exist, but our paper has aimed to comprehensively summarize the clinical aspects of PVO. Through review of the vast literature on the clinical research of PVO an overview of the clinical characteristics, diagnostic methods, treatment and prognosis is provided.

Computed Tomography and Magnetic Resonance Imaging Parameters Associated with Poor Clinical Outcome in Spondylodiscitis

BACKGROUND

Prognostic factors for the disease course of patients with spondylodiscitis have not been well studied.

METHODS

The prognostic value of initial magnetic resonance imaging (MRI) and computed tomography imaging parameters was analyzed in 62 patients (47% women; mean age ± SD, 71.6 ± 9.6 years) with a confirmed diagnosis of spondylodiscitis. The disease course was separately evaluated during initial treatment response during hospitalization, relapse, and clinical short-term follow-up at 3 months.

RESULTS

Overall CT findings graded as definitely inflammatory (P = 0.006), reduced disc height on MRI (P = 0.044) and fluid-equivalent hyperintensity of discs on T2 short tau inversion recovery-weighted sequences (P = 0.047) were associated with poor initial treatment response. High initial C-reactive protein value (>10.1 mg/dL) was associated with a higher relapse rate (P = 0.038). Risk factors for poor outcome were infection with low-virulence bacteria (P = 0.040) and overall MRI findings atypical for infection (P = 0.027).

CONCLUSIONS

Compared with MRI, CT imaging parameters have a higher prognostic value regarding the disease course. Patients infected with low-virulence bacteria and atypical MRI findings are at higher risk for poor clinical outcome and thus warrant closer monitoring.

High cervical spine spondylodiscitis management and literature review

Summary Spondylodiscitis affecting the cervical spine is the most unusual type. Disease progression can be dramatic, even causing quadriplegia and death. We present an unusual case that progressed with osteolytic lesions between C2 and C3, causing cord compression and epidural abscess. The patient was treated surgically by a double approach and improved without neurological deficits and with better inflammatory markers. We reviewed the current literature on the subject.

Septic arthritis of the facet joint

OBJECTIVE

Septic arthritis of the facet joint is a rare clinical entity. We report 11 cases of facet joint infections diagnosed in our institution.

PATIENTS AND METHOD

Patients were identified via the computerized patients record (PMSI). Their features were collected and compared with published data.

RESULTS

The clinical symptoms are similar to those of infectious spondylodiscitis: back pain with stiffness (11/11), fever (9/11), radicular pain (5/11), and asthenia. Ten patients presented with lumbar infection and 1 with dorsal infection. An inflammatory syndrome was observed in every case. A rapid access to spine MRI allowed making the diagnosis in every case, and assessing a potential extension of infection (epidural extension 5/11, paraspinal extension 5/11). Blood culture (8/11) or culture of spinal samples allowed identifying the causative bacterium in every case and adapting the antibiotic treatment. The bacteria identified in our series were different from previously reported ones, with less staphylococci. The origin of the infection was found in 4 cases. Another localization of infection was observed in 4 cases. The outcome was favorable with medical treatment in 10 cases. An abscess was surgically drained in 1 case. None of our patients presented with neurological complications, probably because of the rapid diagnosis.

CONCLUSION

Assessing the facet joint is essential in case of inflammatory back pain, and the radiologist must be asked to perform this examination.

Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial

BACKGROUND

Duration of treatment for patients with vertebral osteomyelitis is mainly based on expert recommendation rather than evidence. We aimed to establish whether 6 weeks of antibiotic treatment is non-inferior to 12 weeks in patients with pyogenic vertebral osteomyelitis.

METHODS

In this open-label, non-inferiority, randomised controlled trial, we enrolled patients aged 18 years or older with microbiologically confirmed pyogenic vertebral osteomyelitis and typical radiological features from 71 medical care centres across France. Patients were randomly assigned to either 6 weeks or 12 weeks of antibiotic treatment (physician's choice in accordance with French guidelines) by a computer-generated randomisation list of permuted blocks, stratified by centre. The primary endpoint was the proportion of patients who were classified as cured at 1 year by a masked independent validation committee, analysed by intention to treat. Non-inferiority would be declared if the proportion of cured patients assigned to 6 weeks of treatment was not less than the proportion of cured patients assigned to 12 weeks of treatment, within statistical variability, by an absolute margin of 10%. This trial is registered with EudraCT, number 2006-000951-18, and Clinical Trials.gov, number NCT00764114.

FINDINGS

Between Nov 15, 2006, and March 15, 2011, 359 patients were randomly assigned, of whom six in the 6-week group and two in the 12-week group were excluded after randomisation. 176 patients assigned to the 6-week treatment regimen and 175 to the 12-week treatment regimen were analysed by intention to treat. 160 (90·9%) of 176 patients in the 6-week group and 159 (90·9%) of 175 of those in the 12-week group met the criteria for clinical cure. The difference between the groups (0·05%, 95% CI -6·2 to 6·3) showed the non-inferiority of the 6-week regimen when compared with the 12-week regimen. 50 patients in the 6-week group and 51 in the 12-week group had adverse events, the most common being death (14 [8%] in the 6-week group vs 12 [7%] in the 12-week group), antibiotic intolerance (12 [7%] vs 9 [5%]), cardiorespiratory failure (7 [4%] vs 12 [7%]), and neurological complications (7 [4%] vs 3 [2%]).

INTERPRETATION

6 weeks of antibiotic treatment is not inferior to 12 weeks of antibiotic treatment with respect to the proportion of patients with pyogenic vertebral osteomyelitis cured at 1 year, which suggests that the standard antibiotic treatment duration for patients with this disease could be reduced to 6 weeks.

FUNDING

French Ministry of Health.

Spondylodiscitis by drug-multiresistant bacteria: a single-center experience of 25 cases

BACKGROUND CONTEXT

Although the incidence of pyogenic spinal infections is increasing, the ideal treatment of spondylodiscitis is still a controversially discussed issue. Furthermore, the proportion of multiresistant bacteria in spondylodiscitis is increasing, and treatment recommendations or reported results are missing for this especially difficult subset of patients.

PURPOSE

The aim of this study is to evaluate the surgical outcome and the postoperative antibacterial treatment regime.

STUDY DESIGN

Retrospective case series.

PATIENT SAMPLE

Patients treated for a spondylodiscitis from multiresistant bacteria at our department between 2006 and 2011.

METHODS

Data were gathered through review of patients' case notes, relevant imaging, and electronic records. Magnetic resonance imaging of the whole spine including gadolinium (Gd)-enhanced T1 sequences and computed tomography scans of the affected regions were obtained in all cases.

OUTCOME MEASURES

C-reactive protein (CRP) and complete blood cell count were analyzed in all cases using routine laboratory techniques. Neurologic deficits were classified according to the American Spinal Injury Association (ASIA) impairment scale.

RESULTS

Twenty-five patients were identified (15 gram-positive and 10 gram-negative drug-multiresistant bacteria). The mean age at presentation was 66 years, and 14 patients were male (56%). All patients presented with pain, and a neurologic deficit was present in 11 (44%) cases. An epidural abscess was found in 11 (44%) cases. At admission, CRP was elevated in all cases with a mean of 13±9.2 mg/dL. The main source of infection was previous spine surgery (36%). All patients in this series underwent surgical debridement of the infection and instrumentation of the spine. Postoperative intravenous antibiotics were administered for 19±8.6 days followed by 3±0.3 months of oral antibiotic therapy. Eradication of the infection was achieved ultimately in all surviving patients. Out of 11 patients with neurologic deficits, 4 had a full recovery, 4 improved incompletely, and 3 remained unchanged after surgery.

CONCLUSIONS

Staged surgical immobilization and instrumentation and optimal debridement at the interdiscal space and spinal canal is a reliable approach to achieve complete healing of spinal infection with multiresistant bacteria. A period of intravenous antibiotic therapy of 2 to 3 weeks followed by a 3-month oral antibiotic therapy seems appropriate for most cases.

Infectious spondylodiscitis: has there been any evolution in the diagnostic and treatment outcomes?

Objective: To evaluate the clinical and radiological results of treatment of patients with spondylodiscitis. Methods: Imaging exams used in this study were plain radiographs and magnetic resonance imaging of the spine. Results: Data from 33 patients, 10 (30.3%) females and 23 (69.7%) males were evaluated. The average time to diagnosis was four months and 28 days (SD &#177; 1 month and 28 days) and 19 patients (57.5%) presented neurological deficit. Surgical treatment was performed in 22 patients (66.6%) and three patients (9.1%) had complications from the surgery. Conclusions: Despite technological advances in complementary exams, early diagnosis of spondylodiscitis remains a challenge. However, drug treatment associated with surgery shows good results.

Prospective comparison of whole-body (18)F-FDG PET/CT and MRI of the spine in the diagnosis of haematogenous spondylodiscitis

PURPOSE

To prospectively compare (18)F-FDG PET/CT and MRI in the diagnosis of haematogenous spondylodiscitis

METHODS

The study included 26 patients (12 women, 14 men; mean age 59 ± 17 years) with clinical symptoms of infection of the spine. Patients who had had prior spinal surgery or any type of antibiotic therapy in the previous 3 months were excluded from the study. Whole-body PET/CT 60 min after injection of 4.07 MBq/kg of (18)F-FDG and an MRI scan of the spine was performed in all patients. SUVmax in an area surrounding the lesions with the suspicion of infection as well as a background SUVmean in a preserved area of the spine were calculated for quantification. Infection was diagnosed by microbiological documentation in cultures of image-guided spinal puncture fluid or blood. Infection was excluded if symptoms were absent without antimicrobial therapy during a follow-up of at least 6 months.

RESULTS

Spondylodiscitis was confirmed in 18 of the 26 patients. Staphylococcus aureus was found in 8 patients, Mycobacterium tuberculosis in 4, Escherichia coli in 2 and other pathogens in 4. Of the remaining 8 patients, the diagnoses were degenerative spondyloarthropathy in 5 and vertebral fracture in 3. The sensitivity, specificity, and positive and negative predictive value were 83%, 88%, 94% and 70% for (18)F-FDG PET/CT, and 94%, 38%, 77% and 75% for MRI, respectively. The accuracies of (18)F-FDG PET/CT and MRI were similar (84% and 81%, respectively). The combination of (18)F-FDG PET/CT and MRI detected the infection in 100% of the patients with spondylodiscitis. (18)F-FDG uptake, quantified in terms of SUVmax corrected by the background SUVmean, was significantly higher in patients with spondylodiscitis than in those without infection (p < 0.001).

CONCLUSION

Due to its high specificity, (18)F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. Quantification of uptake in terms of SUVmax was able to discriminate infection of the spine from other processes in this series of patients.