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

The Impact of Location on De Novo Spondylodiscitis: Regions Matter but Are Secondary to Comorbidities

Background/Objectives: Primary spondylodiscitis (SD) cases surging in incidence globally remain a diagnostic and therapeutic challenge for physicians. The effect of lesion location on outcomes remains unclear. This study aims to assess the 90-day all-cause readmission rate in patients suffering from spondylodiscitis in different regions of the spine, with a secondary objective of comparing in-hospital mortality rates. Methods: Utilizing the 2020 Nationwide Readmissions Database (NRD), USA, adult patients (>18 years) were selected by diagnosis with ICD-10 codes for primary spondylodiscitis. Patients were categorized by localization into eight groups, excluding multifocal patients. Comparative analysis and logistic regressions were performed. Results: Among 5547 patients, lumbar SD was most prevalent, followed by thoracic and lumbo-sacral regions. Cervical SD had the lowest readmission rate (31.3%) and lower odds versus lumbar SD (adjusted OR = 0.73; p = 0.007). Other regions showed no significant differences. In-hospital mortality varied by location. The sacral region, renal failure, and advanced age were the strongest mortality predictors. Conclusions: While the incidence of spondylodiscitis varies by location on the spine, we found no significant differences in readmission rates across regions. However, there were substantial differences in in-hospital mortality rates. Comorbidities, particularly renal failure and advanced age, appear to outweigh spinal localization as risk factors for mortality and readmission.

Vertebral osteomyelitis: a comparative, single-center study in northwestern China

BACKGROUND

Vertebral osteomyelitis (VO) is an infection of the spine with increasing prevalence due to improved diagnostics and aging populations. Multiple pathogens, including Mycobacterium tuberculosis, Brucella spp., and pyogenic bacteria, can cause VO, making differential diagnosis complex, especially in regions with endemic brucellosis and tuberculosis. Early and accurate diagnosis is essential for appropriate treatment.

METHODS

This was a single-center, retrospective, observational study performed between 2019 and 2022 in Kashi, Xinjiang.

RESULTS

In this study, a total of 319 patients were enrolled, comprising 45.5% with tuberculous vertebral osteomyelitis (TVO; 52.4% females), 37.9% with brucellar vertebral osteomyelitis (BVO; 19.8% females), and 16.6% with pyogenic vertebral osteomyelitis (PVO; 52.8% females). Demographically, TVO had a longer mean time to diagnosis compared to BVO and PVO. BVO was more prevalent in male, and PVO patients had higher rates of spinal surgery history (45.3%) and diabetes (13.2%). Clinically, TVO patients presented with fever (72.4%), sweating (83.4%), weight loss (71.7%), and appetite loss (84.8%) more frequently, while BVO patients reported more lower back pain (86.0%). Laboratory investigations revealed significantly higher leucocyte and neutrophil levels in PVO, whereas TVO patients had elevated monocyte-to-lymphocyte and platelet-to-lymphocyte ratios. Radiologically, TVO patients exhibited a higher incidence of thoracic involvement (56.6%) and skip lesions (20%). Microbiologically, BVO and PVO had high positive culture rates (84.3 and 84.9%, respectively), with M. tuberculosis isolated from only 4.1% of TVO patients.

CONCLUSION

These findings underscore the distinct clinical, laboratory, and radiological characteristics of TVO, BVO, and PVO.

Management of Pyogenic Spondylodiscitis in Adults

High index of suspicion, MRI, multidisciplinary collaboration, and CT-guided biopsy are the cornerstones for an early diagnosis of infectious spondylodiscitis. The incidence of spondylodiscitis admissions is increasing. A notable proportion of patients present with neurological deficit. Unfortunately, IV drug users, frail and immunocompromised patients, and patients with HIV are most susceptible to have pyogenic spondylodiscitis and its complications. These infections have a mortality rate of up to 20%. Pyogenic spondylodiscitis should be managed with at least 6 weeks of IV antibiotics. It is best to involve an infectious disease specialist because of the wide variety of organisms involved and the emergence of resistance. Neurological deficits, instability, pain, deformity, and frailty are the factors that decide whether and when to perform surgery. Surgery can reduce morbidity, mortality, and length of hospital stay for these debilitating infections. Some studies have recommended stabilization without aggressive débridement, especially in frail patients. Implants (titanium and PEEK) as well as bone grafts (autograft and allograft) are safe in pyogenic spondylodiscitis. Minimally invasive spinal surgery reduces blood loss, surgical time, and hospital stay over classical open surgery. Endoscopic spine surgery is useful for debulking the infection and obtaining samples for diagnostic purposes.

Medical versus surgical treatment of spondylodiscitis: does surgery spare resources?

The optimal management of spondylodiscitis is still controversial. Large spectrum or targeted antibiotic therapy is the first option in neurologically intact patients, while surgery is reserved for cases of intractable pain, acute neurological defects and bone destruction-related spinal instability. Treatment failure due to lack of diagnosis may lead to infection persistence and progression, causing patients to shift from the medical to the surgical arm. In a 10 years' time, we treated 84 patients affected by primary spontaneous pyogenic spondylodiscitis. Forty-two patients underwent antibiotic therapy alone, 42 posterior fixation/decompression and disc debridement. At admission, we assessed all patients for neurological deficits and pain intensity, using appropriate imaging to rule out instability/neural compression. We compared the two groups in terms of pain control, mobilization, length of hospital stay, antibiotic therapy, and complications. Patients undergoing surgical treatment presented significantly shorter hospital stay, earlier and better pain control, faster mobilization from bed, shorter use of brace and shorter antibiotic therapy courses. No major complications occurred in both groups, while one revision was performed due to wound failure. In agreement with our results, posterior vertebral decompression and fixation should be considered a viable option in cases of spondylodiscitis with severe pain and/or neurological impairment. The operated patients fared clinically well (despite starting from worse clinical conditions than their medical counterparts) and the complication rate was negligible.

Transforaminal interbody debridement and fusion with antibiotic-impregnated bone graft to treat pyogenic discitis and vertebral osteomyelitis: a comparative study in Asian population

STUDY DESIGN

A retrospective cohort study.

PURPOSE

To evaluate whether using antibiotic-impregnated bone graft (AIBG) enhances infection control and shortens the postoperative course of pyogenic discitis and vertebral osteomyelitis (PDVO).

OVERVIEW OF LITERATURE

Surgical treatment of PDVO is indicated for neurological deficit, instability, unknown pathogen, or poorly controlled infection. The posterior-only approach is effective but requires 4-6 weeks of antibiotic treatment postoperatively. We hypothesized that AIBG used in an all-posterior approach could enhance infection control and shorten the postoperative course of PDVO.

METHODS

Thirty patients with PDVO of the lumbar or thoracic spine treated with transforaminal interbody debridement and fusion (TIDF) with AIBG between March 2014 and May 2022 were reviewed (AIBG group). For comparative analysis, 28 PDVO patients who underwent TIDF without AIBG between January 2009 and June 2011 were enrolled (non-AIBG group). The minimum follow-up duration was 2 years. Clinical characteristics and surgical indications were comparable in the two groups. C-reactive protein (CRP) levels and the postoperative antibiotics course were compared between the two groups.

RESULTS

Surgical treatment for PDVO resulted in clinical improvement and adequate infection control. Despite the shorter postoperative intravenous antibiotic duration (mean: 19.0 days vs. 39.8 days), the AIBG group had significantly lower CRP levels at postoperative 4 and 6 weeks. The mean Visual Analog Scale pain scores improved from 7.3 preoperatively to 2.2 at 6 weeks postoperatively. The average angle correction at the last follow-up was 7.9°.

CONCLUSIONS

TIDF with AIBG for PDVO can achieve local infection control with a faster reduction in CRP levels, leading to a shorter antibiotic duration.

Vertebral osteomyelitis in patients with an underlying malignancy or chronic kidney disease - who is at higher risk for adverse outcome?

PURPOSE

Patients with vertebral osteomyelitis (VO) and comorbidities, notably chronic kidney disease (CKD), are at risk of early mortality. The aim of this study was to compare characteristics and outcomes of VO patients with an underlying malignancy (ONCO) to VO patients with CKD and VO patients without comorbidities (CONTROL).

METHODS

We performed a retrospective analysis of data which was prospectively collected between 2008 and 2020. Primary outcome was treatment failure defined as death and/or recurrence of VO within one year.

RESULTS

241 VO patients (ONCO = 56; CKD = 47; CONTROL = 138) were analysed. Treatment failure occurred in 26% of ONCO and 45% of CKD patients. Staphylococcus aureus was the most common causative pathogen in the CKD (57%) and CONTROL group (43%). ONCO patients showed a broader distribution of common VO-causing pathogens, with coagulase-negative staphylococci (CoNS) accounting for the highest proportion of causative bacteria (27%). Nevertheless, S.aureus was associated with a significantly higher risk of treatment failure in VO ONCO patients.

CONCLUSION

Treatment failure in VO CKD patients was twice as high as in VO ONCO patients. However, both groups showed high treatment failure rates. CoNS should be considered when starting empirical antibiotic treatment in VO ONCO patients. Moreover, oncological patients with VO caused by S.aureus should be monitored closely.