Predictors of conservative treatment for pyogenic spondylitis

Cervical spine infection arising from chronic paronychia: A case report and review of literature

BACKGROUND

Cervical spine pyogenic infection (CSPI) is a rare and challenging form of spinal infection that is typically caused by pyogenic bacteria and primarily affects the cervical vertebral bodies and surrounding tissues. Given its nonspecific symptoms, such as fever and neck pain, early diagnosis is crucial to prevent severe complications, including spinal cord injury. We report a previously unreported case of acute CSPI arising from chronic paronychia, exploring its diagnostic and therapeutic challenges through a review of the current literature.

CASE SUMMARY

The presented case involved a 15-year-old man with CSPI caused by Staphylococcus aureus, which led to complications including bacteremia and a paronychia-associated abscess. Acute pyogenic infection was initially diagnosed by typical symptoms and blood culture. Fever improved after antibiotic treatment while developing progressive limbs dysfunction. Six days after admission, the patient underwent anterior cervical debridement + autogenous iliac bone graft fusion + plate internal fixation and received 12 weeks of antibiotic treatment after the operation. Re-examination 3 years postoperatively showed that the patient had stable cervical fixation, no significant neck pain or upper limb abnormalities, and normal urinary function.

CONCLUSION

Early imaging findings, laboratory markers, and timely antibiotic treatment are crucial for CSPI management, preventing complications and facilitating recovery.

Upper Thoracic Pyogenic Spondylitis With a Paravertebral Abscess Treated With a Combination of Cranked Minimally Invasive Spinal Instrumentation and Negative Pressure Wound Therapy: A Case Report

Pyogenic spondylitis is generally managed conservatively; however, surgical intervention may be required depending on the patient's condition. In this report, we present a case of upper thoracic pyogenic spondylitis with a paravertebral abscess that was successfully treated using negative pressure wound therapy (NPWT) combined with a cranked rod construct and a minimally invasive posterior-only approach. This report was constructed based on previous medical records and imaging findings. A 51-year-old man with a paravertebral abscess developed pyogenic spondylitis of the upper thoracic spine (T2 and T3). Surgical treatment was chosen due to severe neurological deficits and the presence of a paravertebral abscess. However, a posterior approach for drainage and debridement was implemented to avoid damage to proximal organs. Posterior instrumented fixation surgery from the cervical spine (C6) to the thoracic spine (T6) was performed to reduce pain and maintain alignment owing to the instability of the affected vertebrae. After pedicle screw insertion, open debridement and drainage of the T2/T3 disc space and paravertebral abscess were performed using a costotransversectomy window. Because debridement was only partially possible intraoperatively with the posterior approach, NPWT was used in combination with this approach to ensure continuous postoperative drainage. To avoid exposure of the metal instrumentation to the contaminated area, the right-side rod was passed around the drainage side with connectors. Two weeks after NPWT, the wound was closed under general anesthesia. Herein, we describe the successful treatment of primary pyogenic spondylitis with a paravertebral abscess in the upper thoracic spine using posterior instrumentation surgery combined with NPWT. In cases where complete debridement of infected tissue is not achieved, NPWT may serve as a valuable adjunctive treatment.

The Need for Comprehensive Medical Management in Pyogenic Spondylodiscitis: A Review Article

The incidence of spontaneous or primary spondylodiscitis has been increasing over the years, affecting the aging population with multiple comorbidities. Several conditions influencing treatment outcomes stand out, such as diabetes mellitus, renal insufficiency, cardiovascular and respiratory dysfunction, and malnutrition. Due to these, the question arises regarding properly managing their current conditions and pre-existing disease states. Treatment plans must consider all concomitant comorbidities rather than just the infectious process. This can be done with the help of multidisciplinary teams to provide comprehensive care for patients with pyogenic spondylodiscitis. To date, there is no article regarding comprehensive medicine for spontaneous pyogenic spondylodiscitis; hence, this paper reviews the evidence available in current literature, recognizes knowledge gaps, and suggests comprehensive care for treating patients with spinal infections. Pre-requisites for implementing multidisciplinary teams include leadership, administrative support, and team dynamics. This group comprises an appointed leader, coordinator, and different subspecialists, such as orthopedic surgeons, infectious disease specialists, internists, rehabilitation doctors, psychiatrists, microbiologists, radiologists, nutritionists, pharmacologists, nurses, and orthotists working together with mutual trust and respect. Employing collaborative teams allows faster time for diagnosis and improves clinical outcomes, better quality of life, and patient satisfaction. Forefront communication is clear and open between all team members to provide holistic patient care. With these in mind, the need for employing multidisciplinary teams and the feasibility of its implementation emerges, showing a promising and logical path toward providing comprehensive care in managing multimorbid patients with pyogenic spondylodiscitis.

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.

Spinal epidural abscess as predicting factor for the necessity of early surgical intervention in patients with pyogenic spondylitis

BACKGROUND

Pyogenic spondylitis is a condition with low incidence that can lead to neurological sequelae and even life-threatening conditions. While conservative methods, including antibiotics and bracing, are considered the first-line treatment option for pyogenic spondylitis, it is important to identify patients who require early surgical intervention to prevent progressive neurologic deficits or deterioration of the systemic condition. Surgical treatment should be considered in patients with progressive neurologic deficits or deteriorating systemic condition. However, currently, there is a lack of treatment guidelines, particularly with respect to whether surgical treatment is necessary for pyogenic spondylitis. This study aims to analyze the radiological epidural abscess on MRI and clinical factors to predict the need for early surgical intervention in patients with pyogenic spondylitis and provide comprehensive insight into the necessity of early surgical intervention in these patients.

METHODS

This study retrospectively reviewed 47 patients with pyogenic spondylitis including spondylodiscitis, vertebral osteomyelitis, epidural abscess, and/or psoas abscess. All patients received plain radiographs, and a gadolinium-enhanced magnetic resonance imaging (MRI) scan. All patients have either tissue biopsies and/or blood cultures for the diagnosis of a pathogen. Demographic data, laboratory tests, and clinical predisposing factors including comorbidities and concurrent other infections were analyzed.

RESULTS

We analyzed 47 patients, 25 of whom were female, with a mean age of 70,7 years. MRI revealed that 26 of 47 patients had epidural abscesses. The surgical group had a significantly higher incidence of epidural abscess than the non-surgical group (p = 0.001). In addition, both CRP and initial body temperature (BT) were substantially higher in the surgical group compared to the non-surgical group. There was no significant difference between the surgical group and the non-surgical group in terms of age, gender, comorbidities, and concurrent infectious disorders, as well as the number of affected segments and affected spine levels. However, the surgical group had lengthier hospital stays and received more antibiotics.

CONCLUSION

The presence of an epidural abscess on MRI should be regarded crucial in the decision-making process for early surgical treatment in patients with pyogenic spondylitis in order to improve clinical outcomes.

Percutaneous pedicle screw fixation was effective for bone regeneration after a huge vertebral defect due to intractable pyogenic spondylitis caused by methicillin-resistant Staphylococcus aureus: a case report

BACKGROUND

Pyogenic spondylitis by methicillin-resistant Staphylococcus aureus (MRSA) is known to be intractable. In the past, the insertion of an implant into infected vertebra was considered contraindicated in affected patients because it may exacerbate the infection, but there are increasing numbers of reports indicating the usefulness of posterior fixation to correct instability and alleviate infection. Bone grafting is often required to repair large bone defect due to infection, but free grafts can exacerbate infection and are controversial.

CASE PRESENTATION

We present the case of a 58-year-old Asian man with intractable pyogenic spondylitis who had repeated septic shocks due to MRSA. Back pain from repeated pyogenic spondylitis caused by a huge bone defect in L1-2 rendered him unable to sit. Posterior fixation by percutaneous pedicle screws (PPSs) without bone transplantation improved spinal stability and regenerated bone in the huge vertebral defect. He regained his activities of daily living, had no reoccurrence of pyogenic spondylitis nor bacteremia, and was completely cured of the infection without antibiotics after removal of all screws.

CONCLUSIONS

For intractable MRSA pyogenic spondylitis with instability accompanied by a huge bone defect, posterior fixation using PPSs and administration of antibacterial agents stopped the infection, allowed the bone to regenerate, and recovered the patient's activities of daily living.

Acute Lumbar Pyogenic Spondylitis With Multiple Abscesses Complicated by a Septic Shock That Required Emergency Surgical Open Drainage: A Case Report

We treated a patient with pyogenic spondylitis complicated by septic shock, who was saved by emergency surgery. The patient was a 75-year-old man with back pain, fever, and weakness in the lower limbs four days before. Upon admission to our hospital, he had tachycardia, tachypnea, fever, and fluctuating vital signs. His quick sequential organ failure assessment (SOFA) score was 2. Emergent magnetic resonance imaging showed scattered intramuscular abscesses and an epidural abscess. Gram-positive cocci were detected in a blood sample. He was diagnosed with pyogenic spondylitis complicated by sepsis. Intravenous antimicrobial therapy with cefepime, vancomycin, and clindamycin was added. However, he developed tachycardia and hypotension three hours after arrival at our hospital, so he received a blood transfusion and noradrenaline and underwent emergent surgical open drainage since percutaneous drainage was difficult to perform because of scattered abscesses. Paralysis of the proximal lower extremities was recovered after surgery. Postoperatively, the causative organism was found to be methicillin-susceptible Staphylococcus aureus and intravenous antimicrobial therapy for 81 days. Three years after surgery, the patient remains free of recurrence with improvement in the activity of daily living to the extent that he could walk. The outcome of our patient suggests that surgery may be a lifesaving measure in cases whose uncontrollable vital signs by pyogenic spondylitis are complicated by sepsis. Preoperative judgment is extremely important in difficult-to-control cases because surgical invasion can be lethal.

Three-Staged Surgical Strategy as a Combined Approach for Multilevel Cervical Pyogenic Spondylodiscitis

Cervical pyogenic spondylodiscitis is rare but can lead to severe clinical problems that often require aggressive surgical treatment for neurological deterioration and life-threatening conditions. Although combined surgical procedures are often utilized to treat multilevel cervical regions, there is a clinical debate regarding the appropriate order and timing of surgeries using the anterior and posterior approaches. Here, we report a case of severe multilevel cervical pyogenic spondylodiscitis treated using a three-staged surgical strategy consisting of cervical laminectomy, posterior fixation, and anterior corpectomy and fusion with an autologous long bone graft; the outcome was quite favorable. Our report demonstrates the safety and usefulness of three-staged surgery in the multilevel cervical region, especially under urgent situations.