Postoperative Spondylodiscitis Research Articles

Post-Operative Spondylodiscitis in a Patient at Mohammed VI University Hospital/Marrakech (Morocco)

Post-operative infections complicate 1 to 10% of spine surgeries and frequently cause disabling chronic painful after-effects. This is the leading cause of re-operation in the first month post-operatively. This is a 47-year-old female patient who underwent spinal surgery and then became superinfected, presenting for back pain in a febrile and general conservation context in whom the clinical examination noted cauda equina syndrome. The paraclinical assessment allowed us to isolate the staphylococcus aureus and an imaging study concluded to post-operative spondylodiscitis. Faced with this picture, an emergency surgical indication was made and the postoperative outcomes were satisfactory. In short, cauda equina syndrome remains a surgical emergency.

Differential diagnosis and treatment of nosocomial spinal infections in patients after open microdiscectomy (brief literature review)

Surgical site infections (SSI) occur in 0.7‒16.1 % of cases and are one of the most frequent nosocomial complications in spinal neurosurgery. The frequency of SSI after open microdiscectomies varies from 1.9 % to 5.5 % depending on several factors and requires clarification. The causative agents of spinal SSI are most often Staphylococcus aureus, S. epidermidis, methicillin-resistant S. aureus, less frequently anaerobic strains, and Mycobacterium tuberculosis.Symptoms of deep SSI caused by the most common Gram-positive and Gram-negative microflora are usually nonspecific and include fever, back pain, and limited movement. Anaerobic spondylodiscitis is characterized by long-lasting back pain, mainly without an increase in temperature, and a high frequency of epidural abscess formation. The most significant factors in the occurrence of SSI are surgical access, type and duration of surgical intervention, the number of levels operated on at once, the duration of hospitalization, the presence of diabetes, and the patient’s high body mass index. However, the importance of each of these and other factors in the development of SSI after surgical interventions for clinically manifest discogenic pathology continues to be studied. In several studies, open microdiscectomies were statistically significantly associated with a higher frequency of SSI formation. Posterior spondylodesis and implants in the spine increase the risk of SSI development. Prevention of SSI should include preoperative, intraoperative, and postoperative stages, compliance with which can contribute to reducing the risk of SSI. Treatment of purulent spondylodiscitis involves antibiotic therapy and long-term dynamic observation. Indications for surgical intervention are the effectiveness of antibiotic therapy, deterioration of neurological symptoms, and violation of the integrity of the vertebrae with the formation of instability. The issue of choosing the optimal access and volume of surgical intervention for postoperative spondylodiscitis is analyzed in many studies and, first of all, is determined by: localization, the nature of structural changes, the presence of accompanying abscesses, the degree of neurological deficit, the presence or absence of vertebral compression fractures and signs of spondylolisthesis.Postoperative SSI worsens patients’ quality of life and disease prognosis in patients with discogenic pathology. A clear understanding of the individual risk factors of SSI, timely diagnosis, and differentiated treatment can prevent the formation of these dangerous complications and minimize their manifestations.

Microbial spectrum, patient-specific factors, and diagnostics in implant-related postoperative spondylodiscitis

AimsImplant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.MethodsPatients treated for IPOS from January 2006 to December 2020 were included. Patient demographics, parameters upon admission and discharge, radiological imaging, and microbiological results were retrieved from medical records. CT and MRI were analyzed for epidural, paravertebral, and intervertebral abscess formation, vertebral destruction, and endplate involvement. Pathogens were identified by CT-guided or intraoperative biopsy, intraoperative tissue sampling, or implant sonication.ResultsA total of 32 cases of IPOS with a mean patient age of 68.7 years (37.6 to 84.1) were included. Diabetes, age > 60 years, and history of infection were identified as risk factors. Patient presentation upon admission included a mean body temperature of 36.7°C (36.1 to 38.0), back pain at rest (mean visual analogue scale (VAS) mean 5/10) and when mobile (mean VAS 6/10), as well as elevated levels of CRP (mean 76.8 mg/l (0.4 to 202.9)) and white blood cell count (mean 9.2 units/nl (2.6 to 32.8)). Pathogens were identified by CT-guided or conventional biopsy, intraoperative tissue sampling, or sonication, and Gram-positive cocci presented as the most common among them. Antibiotic therapy was established in all cases with pathogen-specific treatment in 23 (71.9%) subjects. Overall 27 (84.4%) patients received treatment by debridement, decompression, and fusion of the affected segment.ConclusionCases of IPOS are rare and share similarities with spontaneous spondylodiscitis. While procedures such as CT-guided biopsy and sonication are valuable tools in the diagnosis of IPOS, MRI and intraoperative tissue sampling remain the gold standard. Research on known principles of PJI such as implant retention versus implant exchange need to be expanded to the field of spine surgery.Cite this article: Bone Jt Open 2023;4(11):832–838.

Spectrum of organism in Post-Operative Spondylodiscitis following Percutaneous Transforaminal Endoscopic Lumbar Discectomy: A series of 19 patients.

Spectrum of organism in Post-Operative Spondylodiscitis following Percutaneous Transforaminal Endoscopic Lumbar Discectomy: A series of 19 patients.

Postoperative Lumbar Spondylodiscitis Following Transforaminal Endoscopy and Outcomes of Transforaminal Lumbar Interbody Fusion

Objective: To describe the presentation spectrum of postoperative spondylodiscitis (POS<i>e</i>) following transforaminal endoscopic lumbar discectomy and to report the outcomes of transforaminal lumbar interbody fusion (TLIF).Methods: This study analyzed all patients with the classic features of POS<i>e</i> who underwent index surgery elsewhere and presented to us. They had not responded to conservative care for 3 weeks and were operated further with open TLIF. The treatment response was judged by the declining values of inflammatory markers, improvements in mobility, and decreases in pain. Patients’ outcomes were analyzed using a visual analogue scale (VAS), the Oswestry Disability Index (ODI), and the occurrence of complications. Radiological outcomes were assessed by fusion and implant stability. The spectrum of the demographic presentation was analyzed. PubMed was searched to find the incidence of POS<i>e</i> and the spectrum of organisms involved.Results: Fifteen patients were operated primarily by interventionalists and four by surgeons among 19 POS<i>e</i> patients who finally underwent TLIF at Stavya Spine Hospital & Research Institute. Organism culture positivity was found in 10 and no culture results were present in 9 cases. All TLIF cases had a follow-up of 52.94 ± 13.66 months (range, 28–71 months). The preoperative back pain VAS improved from 9.47 ± 0.61 (8–10) to 0.42 ± 0.50 (0–1). The leg pain VAS improved from 5.78 ± 4.19 (6–10) to 0.52 ± 0.61 (0–1). The preoperative ODI improved from 87.01 ± 7.70 (73.33–97.79) to 7.36 ± 8.14 (0–26.67). No major complications occurred. Cure of infection and stable reconstruction with fusion were achieved in all patients.Conclusion: POS<i>e</i> has a very low reported incidence. Standardization of training and sterilization would further reduce its incidence. However, aggressive early TLIF in patients with nonresponding POS<i>e</i> produces beneficial results.

Anterior approach arthrodesis - ALIF with use of a titanium cage for treatment of postoperative spondylodiscitis after lumbar microdiscectomy

Introduction. Infectious spondylodiscitis has an incidence of 0.21-3.6%. The best intervention should be individualized, using antibiotics only or combining them with stabilizing surgeries. Case presentation. A 38-year-old man presented with lumbosciatalgia, severe pain and inability to ambulate. Magnetic resonance imaging (MRI) of the lumbar spine showed L5-S1 extruded disc herniation and the patient underwent endoscopic microdiscectomy with complete remission of symptoms. After two weeks, he reported severe low back pain and a return of difficulty to walk. Laboratory tests showed an increase in CRP and ESR. MRI showed signs of lumbar spondylodiscitis. The patient started on broad-spectrum intravenous antibiotic therapy. He evolved with improvement in laboratory parameters and maintenance of low back pain. Due to the failure of conservative treatment, anterior approach arthrodesis (ALIF) was chosen, with the complete improvement of the low back pain and the return of the ability to walk. Discussion. Postoperative spondylodiscitis’ frequency depends on the invasiveness of the operation and the type of surgery performed. The most likely source of infection is direct inoculation by virulent pathogens during surgery. A diagnosis delay of more than two months is considered a risk factor for generating adverse results. A Conservative approach is indicated for the patient who is neurologically intact and with minimal bone destruction. Surgical indications are the presence of neurological deficits, intraspinal abscesses, extensive bone destruction, and failure of conservative management. ALIF is supported in the literature because it allows wide exposure of the entire disc space through efficient access to the spine with the complete evacuation of the disc, avoiding dissection of perineural scar tissue and preserving the articular facets. Conclusion. Early diagnosis and treatment are crucial, although there is still no consensus about the best treatment approach. The use of a titanium cage with a bioglass graft had a good response in pain and infection control in our case.

VERTEBRAL OSTEOMİYELİT: SON 10 YILDA NELER DEĞİŞTİ?

Objective: This study was conducted to describe the demographic, clinical, and microbiological characteristics of vertebral osteomyelitis in the last decade, mainly by comparing literature and the previous case series performed in our center.
 Material and Methods: This is a retrospective, observational, descriptive study performed between 2009-2019 at Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine. All patients were divided into three main groups: pyogenic (PVO), tuberculous (TVO) and brucellar (BVO). 
 Results: A total of 100 cases were included in this study. Of these 100 patients, 59 had pyogenic, 15 had brucellar and 26 had tuberculous spondylodiscitis. The disease developed postoperatively in 22 (37.4%) of the 59 PVO cases. The common isolated microorganism was Staphylococcus aureus (n = 11), followed by coagulase negative staphylococci (n = 6). BVO rate was lower than previous case series (15 vs. 24). The median time to improvement in the laboratory findings after the administration of the appropriate treatment was 14 days. PET-CT was diagnostic in 81.8% of PVO patients, similar to MRI. However, PET-CT diagnosis rate was significantly low in TVO patients (3 out of 9, p = 0.040).
 Conclusion: S. aureus remained the most common etiologic agent. Coagulase negative staphylococci infection rate, mainly related to spinal surgery, and postoperative spondylodiscitis rate is higher than before. Brucellar VO rate is lower, which is mostly related to effective animal vaccination and pasteurization. Although, MRI is the gold standard, PET-CT is a promising technique in diagnosis for PVO.

Revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis

To evaluate the incidence and indications for revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis. A retrospective single-center study enrolled 1233 patients with lumbar spine stenosis who underwent spinal decompression and fusion surgery between 2014 and 2018. The number and causes of readmission were evaluated. There were 164 readmissions. Revision surgery at the same level was performed in 63 patients (38.4%), at the higher level - 72 (43.9%), at the lower level - in 29 (17.7%) patients. The most common indication for readmission was spondyloarthrosis with facet joint syndrome (94 (57.3%) patients). The second common complication was pseudoarthrosis (26 (15.9%) patients). These ones comprised 2.1% of all patients with lumbar spine stenosis. The most common indication for readmission was adjacent segment degeneration. The most severe complications requiring complex and even multiple stage revision surgery were pseudoarthrosis and postoperative spondylodiscitis. Causes of readmission are significantly changing at different periods after surgery.

Frequency and characteristics of bacterial and viral low-grade infections of the intervertebral discs: a prospective, observational study

Study designMonocentric, prospective, observational study.ObjectiveThe clinical relevance of bacterial colonization of intervertebral discs is controversial. This study aimed to determine a possible relationship between bacterial and viral colonization and low-grade infection of the discs.MethodsWe investigated 447 disc samples from 392 patients. Microbiological culture was used to examine the samples for bacterial growth, polymerase chain reaction (PCR) was used for detection of herpes simplex virus types 1 and 2 (HSV-1, HSV-2) and Cytomegalovirus (CMV), and histopathological analysis was used to detect signs of inflammation. The results were compared between subgroups organized according to gender, age, location of the samples, surgical approach, preoperative C-reactive protein (CRP), preoperative and 6 months postoperative Oswestry Disability Index (ODI) and Neck Disability Index (NDI), and Modic changes (MC) of the corresponding endplates. Also, we assessed the occurrence of postoperative infections within 6 months.ResultsMicrobiological culture was positive in 38.78% of the analyzed intervertebral discs. Altogether, 180 bacteria were isolated. Coagulase-negative staphylococci (CONS) (23.41%) and Cutibacterium acnes (18.05%) were the most frequently detected microorganisms. None of HSV-1, HSV-2, or CMV were detected. Male patients (p = 0.00036) and cervical segments (p = 0.00001) showed higher rates of positive culture results. Ventral surgical approaches ( p < 0.001) and Type 2 MC (p = 0.0127) were significantly associated with a positive microbiological result ( p< 0.001). Neither pre- nor postoperative ODI and NDI are associated with positive culture results. In 4 (1.02%) patients, postoperative spondylodiscitis occurred.ConclusionsWith 447 segments from 392 patients, we present one of the largest studies to date. While disc degeneration caused by HSV-1, HSV-2, and CMV seems unlikely, we found positive microbiological culture results in 38.78% of all discs. The role of local skin flora and sample contamination should be the focus of further investigations.Level of EvidenceIII.Trial registration: The study was registered at ClinicalTrials.gov (ID: NCT04712487, https://www.clinicaltrials.gov/ct2/show/study/NCT04712487).

Fusion with Stabilization for the Treatment of Post-operative Lumbar Spondylodiscitis: Our Experience

Objective: To analyse the outcome of fusion with stabilization for the treatment of postoperative lumbar spondylodiscitis. Background: Post-operative spondylodiscitis is a dreadful complication following disc surgery. Treatment option is either conservative or operative, but till date, there are no universally accepted treatment protocol. Many studies suggest early surgical intervention provides good outcome. Different mode of surgical interventions can be applied for its treatment like debridement only, debridement followed by fusion with or without stabilization. In this study, we treat all of our patients having post-operative spondylodiscitis by fusion with stabilization. Materials &amp; methods: Retrospectively we reviewed 20 cases from January 2016 to July 2021 in Bangabandhu Sheikh Mujib Medical University and other private hospitals of Dhaka, Bangladesh. Post-operative spondylodiscitis was diagnosed according to history, specific clinical findings, laboratory and radiographic investigations. Surgery was the treatment of choice in our cases. Pre and postoperative evaluations were done by the Visual Analog scale (VAS), Nurick score for neurological outcome, Modified Kirkaldy–Willis criteria for functional outcome and Modified Lee’s criteria for fusion assessment. Results: Total number of patients was 20. Mean age was 48 years (range 22-83). Average follow-up period was 12 months. The period between the surgery and the onset of symptoms was 14 to 28 days. Pre-operative VAS score was 8.10±1.7 and post-operatively was 1.7±0.6 at the last follow-up (P&lt; 0.001). Pre &amp; post-operative Nurick score was 2.7 &amp; 0.7. Functional outcome was assessed in our study by Modified Kirkaldy-Willis criteria which shows 90% patient have satisfactory outcome while 10% have unsatisfactory outcome. Modified Lee’s criteria show definitive fusion in 55%, probable fusion in 35% &amp; possible pseudarthrosis in 10% cases. Conclusion: Early diagnosis and proper management are the keys to successful outcome of postoperative spondylodiscitis. Surgical management in the form of fusion and transpedicular fixation can give excellent results. Keywords: Sondylodiscitis, Fusion, Stabilizationp

Neurosurgical Management and Outcome Parameters in 237 Patients with Spondylodiscitis.

Surgical treatment of spondylodiscitis allows for rapid mobilization and shortens hospital stays, which makes surgical treatment the first-line therapy. We aim to describe our experiences with operative treatment on spondylodiscitis and to determine the parameters that are important in the prediction of outcomes. A retrospective review identified 237 patients who were operatively treated for spondylodiscitis in our institution between January 2010 and December 2018. Clinical data were collected through review of electronic records and relevant imaging. In all cases, contrast-enhancing MRI from the infected region of the spine was obtained. Leukocyte count and C-reactive protein concentrations (CRP) were determined in all the patients. We included 237 patients in the study, 87 female (36.7%) and 150 male (63.3%), with a mean age of 71.4 years. Mean follow-up was 31.6 months. Forty-five patients had spondylodiscitis of the cervical, 73 of the thoracic, and 119 of the lumbosacral spine. All the patients with spondylodiscitis of the cervical spine received instrumentation. In thoracic and lumbar spine decompression, surgery without instrumentation was performed in 26 patients as immediate surgery and in a further 28 patients in the early stages following admission, while 138 patients received instrumentation. Eighty-nine patients (37.6%) had concomitant infections. Infection healing occurred in 89% of patients. Favorable outcomes were noted in patients without concomitant infections, with a normalized CRP value and in patients who received antibiotic therapy for more than six weeks (p < 0.05). Unfavorable outcomes were noted in patients with high CRP, postoperative spondylodiscitis, and recurrent spondylodiscitis (p < 0.05). Application of antibiotic therapy for more than six weeks and normalized CRP showed a correlation with favorable outcomes, whereas concomitant infections showed a correlation with unfavorable outcomes. A detailed screening for concomitant infectious diseases is recommended.

Treatment of infectious aortic disease with bovine pericardial tube grafts

Our aim was to evaluate the mid-term outcomes of bovine pericardial tube graft repair for infectious aortic disease in any aortic segment. Between May 2015 and July 2020, 45 patients were treated for infectious aortic disease of the native (n = 9) aorta or after (endo-)graft (n = 36) implantation with bovine pericardial tube grafts. Clinical, infectious details, outcomes and follow-up data were evaluated. All aortic segments underwent pericardial tube graft or bifurcational replacement: the aortic root (n = 12, 27%), ascending aorta (n = 18, 40%), aortic arch (n = 7, 16%), descending aorta (n = 5, 11%), thoraco-abdominal aorta (n = 6, 13%) and abdominal aorta (n = 18, 40%) including the iliac arteries (n = 14, 31%). Organ fistulation (n = 15, 33%) was the most common underlying pathology. Seven patients (16%) expired in-hospital secondary to ongoing sepsis (n = 5, 11%), respiratory failure (n = 1, 2%) and unknown cause (n = 1, 2%). A fungal infection was predictive for in-hospital mortality (P = 0.026, odds ratio: 19.470). After a median follow-up of 11 [first quartile: 2, third quartile 26] months, 9 additional patients (20%) expired and 1 patient developed a postoperative spondylodiscitis at the level of the aortic tube graft. Hence, freedom from proven aortic graft re-infection was 98%. Orthotopic aortic reconstruction using bovine pericardial tube grafts to treat infectious aortic disease is possible in any aortic segment. Organ fistulation is a frequently observed disease mechanism requiring concomitant treatment. Granted, the early attrition rate is substantial, but after the initial period, both survival and freedom from re-infection appear encouraging.

Prognostic factors in management of postoperative spondylodiscitis

BackgroundSpinal infection is an uncommon disease, which may result in serious complications with potentially high morbidity and mortality.ObjectiveThe aim was to evaluate the outcome of patients with postoperative spondylodiscitis after management in relation to age, sex, general condition, symptoms, signs, radiological findings, type, and time of intervention.Patients and methodsA prospective study was conducted on 20 patients having postoperative spinal infection managed in the period between June 2017 to June 2019 in the Neurosurgery Department at Menoufia University Hospitals and Al Haram Hospital. Patients with postoperative spinal infection were evaluated neurologically by American Spinal Injury Association (ASIA) score, pain was evaluated by Denis score, and they were followed up radiologically by MRI and radiography for assessment of their neurological integrity, deficits, and outcome.ResultsThere was a statistically significant difference between postmanagement Denis pain score, ASIA score, and C-reactive protein as compared with before management (P<0.001). Outcome of the 20 patients was categorized according to Odom's criteria as follows: 12 (60%) patients had excellent outcome, six (30%) patients had good outcome, one (5%) patient had fair outcome, and one (5%) patient had poor outcome.ConclusionAmong the wide variety of organisms responsible for postoperative spinal infection, we found that Staphylococcus aureus accounted for most of it. The best modality of treatment is medical treatment with antibiotics and surgical management when failure of the medical one or presence of neurological deficits.

Open Transforaminal Lumbar Interbody Fusion (TLIF) for post-discectomy spondylodiscitis: Our experience

Introduction: Post operative lumbar Spondylodiscitis after lumbar discectomy surgery is well known complication with has a variable incidence rate, usually less than 1%.1 Post op spondylodiscitis is an infection of nucleus pulposus , annulus fibrosis with sometimes secondary involvement of cartilaginous end plates and vertebral bodies following lumbar disc surgeries.2 Early diagnosis of discitis based on clinical, laboratory, radiological findings and appropriate management is essential to reduce morbidity. Aim: Retrospective review of patients undergoing transforaminal lumbar interbody fusion (TLIF) for post-op discitis to evaluate clinical outcome and complications. Material and Methods:All patients undergone TLIF for post-lumbar discectomy spondylodiscitis at our institute from sept'13 to sept'17 were included in our study. All patients had moderate to severe lumbar backage. Initialy a course of conservative treatment with broad spectrum I .V antibiotics was given followed by surgery. On follow up patients were assessed with physical examination and radiographs. Outcome were measured in terms of operative time, blood loss, and surgical complications. Parameters like Visual analogue scale(VAS) for pain,modified Rankin scale (mRS) were evaluate before and after surgery and on subsequent follow up visits. Results: Modified Rankin scale (mRS) and VAS enhanced in all patients. Conclusion: Postoperative spondylodiscitis can be successfully managed with transforaminal lumbar interbody fusion (TLIF) and posterior spinal instrumentation. There is significant pain relief and good functional outcome after surgery. Keywords: Spondylodiscitis, Post discectomy infection, Transforaminal Lumbar Interbody Fusion (TLIF), Lumbar disc infection.

Revision Surgery for Postoperative Spondylodiscitis at Cage Level after Posterior Instrumented Fusion in the Lumbar Spine-Anterior Approach Is Not Absolutely Indicated.

Spondylodiscitis at the cage level is rare but remains a challenge for spine surgeons. In this study, the safety and efficacy of revision surgery by a posterior approach to spondylodiscitis developed at the cage level were evaluated, and these data were compared to those of patients treated with revision surgeries using the traditional anterior plus posterior approach for their infections. Twenty-eight patients with postoperative spondylodiscitis underwent revision surgeries to salvage their infections, including 15 patients in the study group (posterior only) and 13 patients in the control group (combined anterior and posterior). Staphylococcus aureus was the most common pathogen in both groups. L4-L5 was the most common infection site in both groups. The operation time (229.5 vs. 449.5 min, p < 0.001) and blood loss (427.7 vs. 1106.9 mL, p < 0.001) were the only two data points that were statistically significantly different between the two groups. In conclusion, a single posterior approach with ipsilateral or contralateral transforaminal lumbar interbody debridement and fusion plus extending instrumentation was safe and effective for spondylodiscitis developed at the cage level. This strategy can decrease the operation time and blood loss.

Delayed postoperative spondylodiscitis in a case of diffuse idiopathic skeletal hyperostosis following surgical intervention for traumatic C7-T1 bifacetal dislocation

Postoperative spinal infections are on the rise owing to the ever-increasing number of spine surgeries. Spinal instrumentation is associated with an infection rate of 2%–8%. Both surgical and patient factors have been associated with infection. Delayed cases of postoperative infection are mostly related to patient-related factors and can be easily missed as they lack the classic clinical and systemic features. However, if left unidentified, progressive involvement of contiguous levels would result in collapse, instability, deformity, and instrumentation failure. A high index of suspicion is to be maintained, and higher imaging options such as magnetic resonance imaging and computed tomography should be used judiciously so as to diagnose infection at the earliest. We herein describe the background history, clinical features, imaging characteristics, and successful management of infective spondylodiscitis following instrumentation in a narrative manner. Relevant literature and management options have also been discussed.

294. Spondylodiscitis After Spine Surgery: Microbiology, Clinical Findings, Outcome and Comparison With Spontaneous Spondylodiscitis

BackgroundAlthough postoperative spondylodiscitis has become a major problem, consensus on empirical antibiotics therapy is still controversial. To find out appropriate management of postoperative spondyodiscitis, this study investigated the microbiology, clinical characteristics, and outcome of postoperative pyogenic spondylodiscitis (P-PS) and compared with spontaneous pyogenic spondylodiscitis (S-PS).MethodsThis retrospective cohort study evaluated patients with microbiologically proven spondylodiscitis from three university-affiliated hospitals in South Korea between January 2005 and December 2015, with a follow-up of at least 12 months after completion of antibiotics or until the patient was transferred. Patients with prosthesis at the time of diagnosis of spondylodiscitis or who had a spine operation within 1 year of the diagnosis of spondylodiscitis were defined as having postoperative spondylodiscitis. The spine operations included discectomy, laminectomy, arthrodesis, and instrumentation for stabilization of the spine.ResultsThe study evaluated 104 patients with P-PS and 441 patients with S-PS. In P-PS, the most common isolate was S. aureus (34%), followed by coagulase-negative staphylococci (31%), and the proportion of methicillin-resistant strains was 75%. In S-PS, the most common isolates were S. aureus (47%) and streptococci (21%). Of the staphylococci, 39% were methicillin resistant in S-PS. The proportion of patients with Gram-negative bacilli was 14% in P-PS and 20% in S-PS. Pre-existing or synchronous nonspinal infection (13% vs. 33%, P < 0.001) was observed more frequently in S-PS. Although the duration of antibiotic use was similar in both groups, surgical procedures were done more frequently in P-PS. The mortality rate was similar in both groups. However, the treatment failure and relapse rates at 12 months were higher in the P-PS group (23% vs. 13%, P = 0.009; 14% vs. 7%, P = 0.028, respectively). Methicillin-resistant S. aureus was associated with treatment failure or relapse.ConclusionGram-positive organisms, mainly methicillin-resistant staphylococci, should be considered when prescribing empirical antibiotics in P-PS. Although surgical drainage was applied more often in P-PS than in S-PS, the treatment failure and relapse rates at the 12-month follow-up were higher in P-PS.Disclosures All authors: No reported disclosures.

One-stage posterior debridement and fusion combined with irrigation and drainage for the treatment of postoperative lumbar spondylodiscitis

ObjectiveThe aim of this study was to evaluate the clinical outcomes of one-stage posterior debridement, interbody fusion, and instrumentation, combined with irrigation and drainage, for treating lumbar spondylodiscitis. MethodsThe study included 23 patients (13 male and 10 female, mean age: 45 years) who had posterior debridement, interbody fusion, and instrumentation, followed by continuous closed irrigation and drainage for lumbar postoperative spondylodiscitis. The visual analog scale, Oswestry disability index, and lumbar lordosis angle were assessed before and after surgery to evaluate the clinical outcome. ResultsThe mean follow-up time was 27 (24–36) months. All patients tolerated the procedure well, and there were no instances of spondylodiscitis recurrence, though a dorsal dermal sinus developed in one patient after surgery. Infection was eliminated, as evidenced by the normalization of the erythrocyte sedimentation rates and C-reactive protein levels. The mean visual analog scale scores were significantly decreased after the operation. The mean lumbar lordosis angle before surgery was 21.61 ± 6.88° and the angle at the final follow-up was 31.61 ± 4.24°. The mean Oswestry disability index scores improved significantly both after the operation and at the follow-up visits (p < 0.05). Bone union was confirmed in all patients at a mean of 8.6 months post-operation, though this was not achieved until 2 years post-operation in one patient. All 3 patients who had neurological deficits showed great improvement at the last follow-up. ConclusionSurgical management using one-stage posterior debridement, interbody fusion, and instrumentation, followed by continuous closed irrigation and drainage, might be an effective treatment option for lumbar postoperative spondylodiscitis. Level of evidenceLevel IV, Therapeutic study.

Imaging of postoperative spinal infections

The spectrum of postoperative spinal infections includes superficial and deep infections, wound infections, spondylodiscitis, intraspinal epidural abscess, infective arachnoiditis, the extraspinal pre- and paravertebral extension of intraspinal abscesses, and necrotic collections. Imaging modalities for detection of these pathologies include plain radiographs, multidetector computed tomography, magnetic resonance imaging (MRI), and radionucleotide scintigraphy. MRI allows adequate visualization of both the bony structures and soft tissues. Contrast enhanced MRI with gadolinium is the imaging modality of choice to delineate postprocedural and postoperative spine infections and complications. MRI has high sensitivity and specificity in the diagnosis of postoperative spondylodiscitis, epidural abscesses, and infective arachnoiditis. Metallic orthopedic hardware may produce artifacts that degrade image quality which is resolved by a metal artifacts reduction sequence to optimize the image quality in bone and soft tissues. F-18 fluorodeoxyglucose positron-emitted tomography is superior to MRI not only in patients with surgical history and high grade infection but also in the patient with low grade spondylodiscitis.

Prolonged and high dosage of tigecycline \u2013 successful treatment of spondylodiscitis caused by multidrug-resistant Acinetobacter baumannii: a case report

BackgroundThe incidence of infectious spondylodiscitis has been increasing over the last few years. This reflects the expanding elderly and immunocompromised populations and the rising implementation of invasive spinal procedures. Infection may be inoculated into the disc space directly during invasive spinal procedures. Osteomyelitis caused by Acinetobacter species is rare and mainly caused by multidrug-resistant strains.Case presentationWe present the case of a 72-year-old Greek woman with postoperative spondylodiscitis caused by a multidrug-resistant Acinetobacter baumannii strain that was successfully treated, after she declined surgical treatment, with prolonged and high dosage of tigecycline. She received intravenously administered tigecycline 200 mg per day for 60 days and then 100 mg per day for a total of 102 days and was infection-free.ConclusionsWe reviewed the literature on the role of Acinetobacter baumannii as a cause of osteomyelitis, emphasizing the difficulty of treatment and the potential role of tigecycline in conservative treatment of the infection. We believe that 102 days in total is the longest time that any patient has received tigecycline in the literature, thus our patient is a unique case of successful treatment of spondylodiscitis.