Hematogenous Spondylodiscitis Research Articles

Tumors and infections of the growing spine.

The growing spine differs from the adult spine in several ways. Although tumors and infections cause only a small percentage of pediatric back pain incidences, delayed proper diagnosis and treatment may be disastrous. Benign lesions, such as osteoid osteoma, osteoblastoma, and aneurysmal bone cyst in the spine, are predominant during the first two decades of life, whereas malignant bony spinal tumors are rare. In the pediatric population, malignant spine tumors include osteosarcoma, Ewing's sarcoma, lymphoma, and metastatic neuroblastoma. Infections of the growing spine are rare, with the incidence of discitis peaking in patients under the age of 5 years and that of vertebral osteomyelitis peaking in older children. Spondylodiscitis is often a benign, self-limiting condition with low potential for bone destruction. Conservative treatments, including bedrest, immobilization, and antibiotics, are usually sufficient. Spinal tuberculosis is a frequently observed form of skeletal tuberculosis, especially in developing countries. Indications for surgical treatment include neurologic deficit, spinal instability, progressive kyphosis, late-onset paraplegia, and advanced disease unresponsive to nonoperative treatment. Spinal tumors and infections should be considered potential diagnoses in cases with spinal pain unrelated to the child's activity, accompanied by fever, malaise, and weight loss. In spinal tumors, early diagnosis, fast and adequate multidisciplinary management, appropriate en bloc resection, and reconstruction improve local control, survival, and quality of life. Pyogenic, hematogenous spondylodiscitis is the most common spinal infection; however, tuberculosis-induced spondylodiscitis should also be considered. Level of evidence: level 4.

SILVER-COATED IMPLANTS IN SPINE SURGERY

Infections in spine surgery are relatively common and devastating complications, a significant burden to the patient and the healthcare system. Usually, the treatment of SSIs consists of aggressive and prolonged antibiotic therapy, multiple debridements, and in chronic cases, hardware removal. Infections are correlated with worse subjective outcomes and even higher mortality.Depending on the type of spine surgery, the infection rate has been reported to be as higher as 20%. Recently silver-coated implants have been introduced in spine surgery to reduce the incidence of post-operative infections and to improve implant survivorship.The aim of the present study is to evaluate complications and outcomes in patients treated with silver-coated implants because of spine infection.All consecutive patients who had spine stabilization with a silver-coated implant from 2018 to 2021 were screened for inclusion in the study. Inclusion criteria were: (1) six months of minimum follow-up; (2) previous surgical site infection; hematogenous spondylodiscitis requiring surgical stabilization. Demographic and surgical information were obtained via chart review, all the device-related complications and the reoperation rate were also reported.A total of 57 patients were included in the present study. The mean age was 63.4 years, and there were 36 (63%) males and 21 (37%) females. Among the included cases, 57% were SSIs, 33% were spondylodiscitis, and 9% were hardware mobilization.Comorbidities such as diabetes mellitus, obesity, smoke, and oncological history were significant risk factors. In addition, the organisms cultured were Staphylococcus species in most of the cases. At six months of follow-up, 40% of patients were considered free from infection, while 20% needed multiple surgeries.The present research showed satisfactory results of silver-coated implants for the treatment of spine infection.

Infectious hematogenous lumbar spondylodiscitis caused by Actinotignum schaalii in a 74-year-old man: A case report.

Infectious hematogenous spondylodiscitis (HS) requires urgent treatment. In some cases, the germ detection of very slow growing bacteria can be challenging and a life threatening HS can easily be overlooked. A Parkinson's patient presented with slowly increasing immobilising back pain for three months and a deterioration of his general condition. A lumbar spondylodiscitis (L1/2) was diagnosed. We indicated surgical exploration with debridement and dorsal instrumented stabilization (L1-2). On the fifth postoperative day, the patient complained again of severe back pain, caused by implant dislocation. We extended the instrumentation in a revision procedure (Th12-L4). After 5 days of incubation, a pan sensitive Actinotignum schaalii could be detected microbiologically. The patient was discharged free of infection within 14 days after surgery with appropriate oral antibiotic therapy. Actinotignum schaalii is difficult to detect but can be successfully treated. Actinotignum species rarely grow under normal urine culture conditions. In chronic inflammation, as a cause of gradual weight loss, anemia and back pain, Actinotignum schaalii should be considered as a causative agent in the ageing population. In cases of severe HS and comorbidities, a definitive surgical solution is required. A HS caused by Actinotignum schaalii is rare. Particularly in cases where a bacterial infection is suspected, prolonged incubation under appropriate conditions is essential. Surgical debridement and prolonged antibiotic treatment are substantial to cure the patient. • Haematogenous bacterial spondylodiscitis due to infection with a well-treatable but easily overlooked and often underdiagnosed pathogen. • An argument against short pedicle screw instrumentation, when urgent surgical therapy of the infected spine is required, in patients with PD and poor general condition. • Especially in cases where a bacterial infection is suspected clinically and by imaging, the detection of germs must be forced by all means in order to be able to treat the patients well.

Terminology of bone and joint infection.

Bone & Joint ResearchVol. 10, No. 11 InfographicOpen AccessOpen Access licenseTerminology of bone and joint infectionCrossmarkMarkus Rupp, Nike Walter, Susanne Baertl, Siegmund Lang, David W. Lowenberg, Volker AltMarkus RuppConsultantMarkus Rupp. E-mail: E-mail Address: [email protected]https://orcid.org/0000-0001-7221-3783 Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany Search for more papers by this author, Nike WalterResearch Associatehttps://orcid.org/0000-0002-0654-2076 Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany Search for more papers by this author, Susanne BaertlResident Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany Search for more papers by this author, Siegmund LangResident Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany Search for more papers by this author, David W. LowenbergClinical Professor Department for Orthopaedic Surgery, Stanford Medical School, Redwood City, California, USA Search for more papers by this author, Volker AltDirector and Chairmanhttps://orcid.org/0000-0003-0208-4650 Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany Search for more papers by this authorPublished Online:17 Nov 2021https://doi.org/10.1302/2046-3758.1011.BJR-2021-0371AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Musculoskeletal infections are common and often difficult to treat.1,2 Their diagnostics and treatment are an integral part of the daily clinical routine of every orthopaedic and trauma surgeon. Diagnostics and first treatment approaches are often initiated prior to referrals to a specialized centre. Treatment algorithms in the field of musculoskeletal infections, based on clinical and experimental empiricism, promise successful treatment courses in many cases,3-5 although a considerable proportion of bone and joint infections are characterized by treatment failure, for a variety of reasons.6The basic prerequisite for the initiation of correct diagnostics, and thus consecutive best possible therapy, is the correct terminology of individual bone and joint infections. A variety of terms exists to describe bone and joint infections. Osteomyelitis, implant-associated infection, fracture-related infection (FRI), and infected nonunion denote bone infections. Joint infections are described by periprosthetic joint infection (PJI) and septic arthritis, with its synonyms of supportive and infectious arthritis. In the spine, a distinction can be made between implant-associated vertebral osteomyelitis and hematogenous spondylodiscitis according to the aetiology. Even among experts in the field, terms are interchanged and used synonymously. It often appears to be difficult to arrive at exact definitions, which naturally limits the understanding of optimal treatment. For FRI and PJI, diagnostic criteria have been developed, and in the case of PJI those criteria have been continuously improved and are still the subject of scientific discussion.7-9To lay the foundation for optimal therapy using the correct terminology of the underlying condition, this infographic presents the hallmarks of bone and joint infections and diagnostic criteria.

Haematogenous Spondylodiscitis in Patients With Liver Cirrhosis: Case Series of 36 Patients.

A retrospective study of 36 liver cirrhosis patients presenting with spondylodiscitis. The aim of this study was to analyze the characteristics of spondylodiscitis in the presence of liver cirrhosis and furthermore, to evaluate the outcome of surgery in this specific group of patients. The incidence of haematogenous spondylodiscitis is increasing. The coexistence of liver cirrhosis makes the course of the disease more aggressive. A total of 36 liver cirrhosis patients presented with haematogenous spondylodiscitis. The onset of infection, clinical course and outcomes of management were reviewed retrospectively. The associated comorbidities were cardiac in 17 patients, diabetes in 19, renal insufficiency in 16, and another focus for infection in nine cases. Neurological deficits were found in 24 patients (67%) and fever in 15 cases. Nine patients had septic manifestations. The lumbar spine was affected in 25 patients (69%). Noncontiguous spinal infection was found in nine patients (25%) and epidural abscess in 24 individuals. The preoperative C-reactive protein was elevated in all cases. The causative organism was most commonly Staphylococcus aureus (17 patients). A combined anteroposterior approach was necessary in 28 patients and a minimallly invasive surgery was performed in 30 cases. In-hospital mortality was 14% (5 patients). The neurological improvement rate was 82%. The postoperative antibiotic therapy was taken for more than 8 weeks in 22 patients. In 15 patients, a combination of antibiotics was necessary. Spinal infection in the presence of liver cirrhosis is challenging. The rate epidural abscess formation is relatively high. Early diagnosis remains the main cornerstone in the management and the indication for surgery should be carefully considered. Minimally invasive techniques should be used when possible to minimize complication rate, and higher amounts of intraoperative blood loss should be expected. 4.

Clinical and microbiological outcomes in haematogenous spondylodiscitis treated conservatively.

Spondylodiscitis refers to infections of the intervertebral disc and the adjacent vertebral body. Although it is still considered a rare condition, its rate is projected to increase. Mortality rate is considered to be low, but an estimated one third of the survivors experience residual disabilities. Literature shows that uncomplicated spondylodiscitis can be adequately treated by early antibiotic therapy and immobilization. The aim of the study is to evaluate the outcome of conservative treatment in patients with haematogenous spondylodiscitis. All patients with haematogenous spondylodiscitis observed in two orthopaedic centres were retrospectively considered. The medical records, radiologic imaging, bacteriology results, treatment, and complications of all patients were reviewed. Thirty patients (median age 64years, range 15-77, females 56.7%) were considered in the study, eight (26.7%) showed residual back pain at median follow-up of 117weeks (range 104-189). A significant difference in SF-36 physical (P<0.001), SF-36 mental function (P<0.002), and Oswestry Disability Index (ODI) (P<0.001) scores was observed among patients with residual local pain compared to the ones who had not. Methicillin-resistant Staphylococcus aureus (MRSA) infection and symptoms duration before the diagnosis were associated with an increased risk of persistent back pain and permanent disability. The most important negative determinants of SF-36 mental function were the age of patients (ρ=0.36, P<0.05), the duration of symptoms before the diagnosis (ρ=0.44, P<0.05) and MRSA infection (P=0.006). Spondylodiscitis sustained by MRSA and the duration of symptoms before the diagnosis influenced negatively the physical status (P=0.002) and ODI (ρ=0.36, P<0.05), respectively. Conservative approaches are safe and effective for patients without complications. A delayed diagnosis and MRSA infections are related to poor clinical outcome among patients treated by conservative treatment; this must be carried out scrupulously with close patient monitoring.

A Retrospective Study of 39 Patients Treated With Anterior Approach of Thoracic and Lumbar Spondylodiscitis: Clinical Manifestations, Anterior Surgical Treatment, and Outcome.

The aim of this study is to report our 39 patients treated with anterior debridement and autologous iliac bone grafting with or without anterior instrumentation, which is the presumed treatment of choice for thoracic or lumbar spondylodiscitis.Our patients underwent surgical treatment of spondylodiscitis using anterior debridement and autologous iliac bone grafting with or without anterior instrumentation and were analyzed with a mean follow-up of 8 years (range, 2–11 years). Kaneda 2-rod system instrumentation was used in 12 patients, in total. Clinical outcomes were assessed by the Frankel grade. Radiographic fusion was characterized based on 3-dimensional computed tomography.Of the whole group, 20 patients suffered from tuberculous spondylodiscitis and 19 suffered from hematogenous spondylodiscitis. Pathogens responsible for pyogenic infection included Staphylococcus aureus (4 patients), Pseudomonas aeruginosa (3 patients), and Brucella melitensis (1 patient). Fifteen patients had thoracic involvement, 20 had lumbar involvement, and 4 had thoracolumbar junction involvement. Preoperative neurological deficits were noted in 13 of the 39 patients. In terms of Frankel grade, 8 patients have improved, 4 have remained the same, and 1 patient has worsened during the follow-up period. Imaging-documented fusion was achieved in 23 of 27 patients in the graft group (85% fusion rate) and 11 of 12 patients in the graft + Kaneda instrumentation group (91% fusion rate).There was no instrumentation failure, loosening, or graft-related complication such as slippage or fracture of the graft. This approach demonstrated a good recovery rate of neurological functions and a high fusion rate.

FDG PET/CT is useful for the interim evaluation of response to therapy in patients affected by haematogenous spondylodiscitis

Antibiotic therapy in patients affected by discitis is often empirical. Therefore, early evaluation of response to therapy is important. In many patients inflammatory indexes are low during all the phases of the diseases or are altered by concomitant diseases. The aim of the study was to assess the possible role of FDG PET/CT for the early evaluation of response to therapy in patients affected by infective discitis, in comparison to C-reactive protein (CRP) serum levels. Enrolled in the study were 38 patients diagnosed with haematogenous infective discitis. Of the 38 patients, 7 had tubercular infection, 1 fungal infection and 30 pyogenic discitis. Four patients were excluded because the second PET/CT scan was not performed. Thus 34 patients (18 women, mean age 64 years) were analysed. All the patients included underwent a FDG PET/CT scan and determination of CRP level at baseline and again 2 to 4 weeks after the start of therapy. The PET results in terms of SUV of the first and second scans (SUV1 and SUV2) and delta-SUVmax were compared to the inflammatory indexes and clinical status during therapy. The mean SUVmax at diagnosis was 8.6 ± 3.7. The mean CRP level at diagnosis was 3.8 ± 3.8 mg/dl. A progressive clinical response was seen in 26 patients and 8 patients showed no response. SUV1 was not correlated with the baseline CRP level (CRP1, p = 0.7) and SUV2 was not correlated with the CRP level at the time of the second scan (CRP2, p = 0.4). In responders, SUV2 and CRP2 were significantly lower than SUV1 and CRP1 (p < 0.0001 and p = 0.001, respectively). ROC curves for delta-SUVmax showed a sensitivity of 82 % and a specificity of 82 % with a cut-off of 34 %. ROC curves for SUV2 showed a sensitivity of 83 % and a specificity of 46 % with a cut-off of 6.4. ROC curves for delta-CRP showed a sensitivity of 67 % and a specificity of 89 % with a cut-off of 74 %. ROC curves for CRP2 showed a sensitivity of 65 % and a specificity of 70 % with a cut-off of 0.7 mg/dl. No statistically significant difference was found between delta-SUVmax AUC and delta-CRP AUC (p = 0.5). Delta-SUVmax provided a higher sensitivity and specificity for identifying responders. SUV2 provided comparable sensitivity, but significantly lower specificity. CRP level performed less well for identifying responders. There was no significant difference in the global performance of the two tests (delta-SUVmax AUC and delta-CRP AUC). However, the higher sensitivity of delta-SUVmax for the early identification of responders may have an important clinical impact in guiding antibiotic therapy especially in patients with a noninformative CRP test at diagnosis.

Septic hematogenous lumbar spondylodiscitis in elderly patients with multiple risk factors: efficacy of posterior stabilization and interbody fusion with iliac crest bone graft

The conservative and operative treatment strategies of hematogenous spondylodiscitis in septic patients with multiple risk factors are controversial. The present series demonstrates the outcome of 18 elderly patients (median age, 72 years) with septic hematogenous spondylodiscitis and intraspinal abscess treated with microsurgical decompression and debridement of the infective tissue, followed by posterior stabilization and interbody fusion with iliac crest bone graft in one or two lumbar segments. The majority of the patients were unsuccessfully treated with intravenous antibiotics prior to the operation. Antibiotic therapy was continued for more than 6 weeks postoperatively. Morbidity and early mortality amounted to 50 and 17%, respectively. Three patients died in the hospital from internal complications after an initial postoperative improvement of the inflammatory clinical signs and laboratory parameters. Fifteen patients recovered from the spinal infection. Three of them died several months after discharge (cerebral hemorrhage, malignancy and unknown cause). Twelve patients had excellent or good outcomes during the follow-up period of at least 1 year. The series shows that operative decompression and eradication of the intraspinal and intervertebral infective tissue with fusion and stabilization via a posterior approach is possible in septic patients with multiple risk factors and leads to good results in those patients, who survive the initial severe stage of the septic disease. However, the morbidity and mortality suggest that this surgical treatment is not the therapy of first choice in high-risk septic patients, but may be considered in patients when conservative management has failed.