Pyogenic Spinal Infection Research Articles

The clinical management and efficacy of metagenomic next-generation sequencing in patients with pyogenic spinal infection: a single-center cohort study

ObjectiveThis study aims to evaluate the clinical management and effectiveness of metagenomic next-generation sequencing (mNGS) in patients with pyogenic spinal infections.MethodsWe conducted a retrospective review of 17 patients diagnosed with pyogenic spinal infections and treated at our institution between October 2022 and February 2024. The cohort included 8 males and 9 females, with a mean age of 63.59 ± 10.18 years (range: 41–71 years). The infections comprised 9 epidural abscesses, 6 intervertebral space infections, and 2 deep abscesses. All patients underwent open surgical procedures and mNGS-based bacterial identification using intraoperative pus or tissue specimens, in addition to conventional blood bacterial cultures. Clinical outcomes were assessed using CRP, PCT, WBC inflammatory markers, and VAS scores postoperatively.ResultsAll 17 patients with pyogenic spinal infections underwent open surgery and mNGS bacterial detection at our institution. Among the 17 patients, mNGS yielded positive results in 14 cases (82.4%), significantly higher than the 5.9% positivity rate of conventional bacterial cultures (p < 0.001). The mNGS test time was notably shorter than conventional cultures (1.0 vs. 5.88 days, p < 0.001). Postoperative antibiotic therapy was adjusted based on mNGS findings. There were significant reductions in postoperative VAS, WBC, PCT, and CRP values compared to preoperative levels (p < 0.01).ConclusionMetagenomic next-generation sequencing is effective in managing pyogenic spinal infections by facilitating rapid and sensitive detection of pathogens. This technique improves the timeliness and accuracy of diagnosis, highlighting its potential for broader clinical use.

Comparing Conservative and Early Surgical Treatments for Pyogenic Spondylodiskitis: An International Propensity Score-Matched Retrospective Outcome Analysis.

Pyogenic spinal infections pose therapeutic challenges, with the optimal treatment approach remaining contentious. This study aimed to compare outcomes of conservative vs early surgical treatment (SuT) modalities in primary pyogenic spondylodiskitis through an international cohort analysis. A retrospective outcome analysis was conducted of 392 patients from the United Kingdom and Germany, treated between 2017 and 2022 with primary pyogenic spondylodiskitis. Patients were stratified by treatment modality. Propensity score matching, facilitated by a directed acyclic graph and principal component analysis, was used to balance risk factors between the compared patient cohorts. Primary outcome was mortality rate, while secondary outcomes included hospitalization duration, infection relapse, and neurological status at discharge. The study included 95 patients undergoing conservative treatment, primarily treated in the United Kingdom, and 297 receiving SuT, predominantly in Germany. The mortality rate was notably higher in the conservative group (P < .001), while the surgical cohort experienced a shorter hospitalization duration (P < .01). After propensity score matching, 2 comparable cohorts of 95 patients each emerged. Subsequent analysis revealed a markedly increased mortality in the conservative group (24.2% for conservative treatment vs 4.2% for SuT, P < .001). Neither relapse nor neurological status at discharge showed significant differences between the groups. The study indicates that early surgical intervention may be more effective than conservative management in reducing mortality and hospital stay for patients with primary pyogenic spondylodiskitis. These findings highlight the need for prospective trials and more definitive treatment guidelines.

From the Oral Cavity to the Spine: Prevalence of Oral Cavity Infections in Patients with Pyogenic Spinal Infection.

Background incidence of pyogenic spinal infections has increased in recent years. In addition to treating the spinal infection, optimal care also includes identifying the source of the pyogenic spinal infection and the presence of other infections. The aim of this study is to elucidate the prevalence of oral cavity infection (OCI) within this patient cohort. Methods As part of a prospective study conducted from 2016 to 2021, the number of patients with dental infections was investigated by means of an orthopantomogram (OPG) and subsequent dental examination. Results The presence of an oral infection was investigated in 55 (47%) of 118 patients by an OPG, 29 (53%) of whom had a corresponding abnormality of the oral cavity. In addition to the spinal infection, patients with an oral cavity infection revealed an increased incidence of endocarditis, sepsis and brain abscess. A spinal epidural abscess, a multilevel affection of the infection, and an elevated CRP value were also found in patients with a co-existing oral cavity infection. Back pain assessed at admission and 3 months after surgery was also more pronounced in patients with an oral cavity infection. Neurological deficits were often present in patients with spinal and oral cavity infection. Conclusions The presence of an oral cavity infection has proven to be one of the important factors in the detection of the source of the pyogenic spinal infection. In addition, a pronounced spinal affection and frequent co-infections were seen in patients with an oral cavity infection.

Risk Factors Associated with Pyogenic Spinal Infections among Intravenous Drug Users and Nonusers.

To identify the differences in patient factors, presentation, treatment course, and outcomes of intravenous drug users (IVDA) vs. nonusers (non-IVDA) presenting with pyogenic spinal infections. Study Design/Setting. Retrospective case series. We identified all cases involving spinal infections at our institution between May 2017 and January 2023. Postsurgical infections were excluded, and patients were separated into IVDA and non-IVDA groups. The patient charts were reviewed and analyzed for statistical or clinically significant differences using RStudio (2019 version 3.6.2). Our institutional review board approved this study, IRB# 2020-277, iRISID-2023-1384. Fifty patients (29 males and 21 females) with primary pyogenic spinal infections were included in our study. There were fourteen patients (28.0%) in the IVDA group. The mean age in the IVDA group was 50.6 vs. 61.9 years (p < 0.05) in the non-IVDA group. The average length of stay (LOS) in the IVDA group was 15.8 vs. 14.0 days (p = 0.54) in the non-IVDA group, with no significant difference in readmissions or disposition. Twenty-three non-IVDA patients were diagnosed with diabetes, while eight IVDA patients had a psychiatric diagnosis (other than substance abuse). There were no significant differences in microbial isolate or the duration of antibiotics. In our study population, there is a high incidence of intravenous drug abuse (IVDA), psychiatric disease, diabetes, and chronic kidney disease. Analysis shows a trend of two distinct patient populations. Patients without a history of IVDA were significantly older than those with IVDA and significantly more likely to have medical comorbidities including hyperlipidemia, diabetes, chronic kidney disease, and malignancy than those with IVDA history. Patients with IVDA were younger with significantly higher rates of smoking and psychiatric disorders. IVDA patients struggled to receive continued psychiatric/addiction treatment after discharge, an area for significant improvement. Due to a small sample size and single urban institution setting, this study may be underpowered to demonstrate differences in healthcare resource consumption.

An international consensus based on the Delphi method to define failure of medical treatment in pyogenic spinal infections

Background contextPyogenic spinal infections (PSIs) are severe conditions with high morbidity and mortality. If medical treatment fails, patients may require surgery, but there is no consensus regarding the definition of medical treatment failure. PurposeTo determine criteria for defining failure of medical treatment in PSI through an international consensus of experts. Study designA two-round basic Delphi method study. SampleOne hundred and fifty experts from 22 countries (authors or co-authors of clinical guidelines or indexed publications on the topic) were invited to participate; 33 answered both rounds defining the criteria. Outcome measuresA scale of 1 to 9 (1: no relevance; 9: highly relevant) applied to each criterion. MethodsWe created an online survey with 10 criteria reported in the literature to define the failure of medical treatment in PSIs. We sent this survey via email to the experts. Agreement among the participants on relevant criteria (score ≥7) was determined. One month later, the second round of evaluations was sent. An extra criterion suggested by six responders in the first round was incorporated. The final version was reached with the criteria considered relevant and with high agreement. ResultsThe consensus definition is: (1) There is an uncontrolled sepsis despite broad spectrum antibiotic treatment, and (2) There is an infection relapse, following a six-week period of antibiotics with clinical and laboratory improvement. ConclusionsOur definition of failure following nonsurgical treatment of PSI can offer a standardized approach to guide clinical decision-making. Furthermore, it has the potential to enhance scientific reporting within this field.

The epidemiology of concurrent infection in patients with pyogenic spine infection and its association with early mortality: A nationwide cohort study based on 10,695 patients

BackgroundGenerally, a sufficient duration of relevant antibiotics based on an appropriate culture combined with proper surgical treatment guarantees a favorable clinical outcome in patients with pyogenic spine infections. However, a patient’s condition often deteriorates as concurrent infections occur in other organs, leading to mortality. Therefore, this study aimed to investigate the epidemiology of concurrent infections in patients with a pyogenic spine infection and estimate the rates and risks of early mortality. MethodsPatients with a pyogenic spine infection were identified using a national claims database that includes the entire population. The epidemiology of the six types of concurrent infections was investigated, and the corresponding early mortality rates and risks were estimated. The results were validated internally by bootstrapping and externally by defining two additional cohorts for sensitivity analysis. ResultsAmong 10,695 patients with a pyogenic spine infection, the prevalence of the six types of concurrent infections was 11.3 % for urinary tract infections, 9.4 % for intra-abdominal infections, 8.5 % for pneumonia, 4.6 % for septic arthritis or osteomyelitis of the extremities, 0.7 % for central nervous system infections, and 0.5 % for cardiac infections. Patients with a concurrent infection had approximately 4-fold greater mortality than those without (3.3 % vs. 0.8 %). The early mortality rates were particularly higher in patients with multiple or specific types of concurrent infections, including central nervous system infections, cardiac infections, and pneumonia. In addition, the mortality trends differed significantly according to the number and type of concurrent infections. ConclusionsThese data on six types of concurrent infection among patients with pyogenic spinal infection can be used as a source of reference by clinicians.

Analysis of Clinical Factors Associated with Medical Burden and Functional Status in Pyogenic Spine Infection

Pyogenic spinal infection (PSI) has recently been on the rise due to aging and increasing degenerative spinal disease related procedures. PSI requires long-term antibiotic treatment and is followed by sustained functional disability even after successful treatment. This study aimed to analyze the clinical factors associated with medical burden and functional status of PSI. This retrospective study involved patients with non-postoperative PSI of thoraco-lumbo-sacral area in a single tertiary hospital. The length/cost of hospitalization with an antibiotic therapy and severity of back pain using the short form 36 (SF-36) were defined as the medical burden and functional status, respectively. We analyzed the clinical factors associated with medical burden and functional status. We enrolled 142 patients (91 males and 51 females). The length and cost of hospitalization were 55.56 ± 27.09 (7-172) days and $14,070.17 ± 9289.39 (1611.87-48,722.35), respectively. A recurrence rate of 7.7% (11/142) and significant improvement of SF-36 at six months after completion of antibiotic treatment were noted (p < 0.05). Procedure-related (OR 2.702), C-reactive protein (CRP; OR 1.062), bacteremia (OR 4.966), additional surgical treatment (OR 6.524), recurrence (OR 12.453), and paraspinal abscess (OR 5.965) for above-average length of hospitalization were observed; female (OR 4.438), CRP (OR 1.071), bacteremia (OR 4.647), additional surgical treatment (OR 6.737), recurrence (OR 22.543), and extent of lesion (OR 1.431) for above-average cost of hospitalization; leg weakness (OR 15.966), white blood cell (WBC; OR 1.116), Charlson's comorbidity index (CCI, OR 1.485), and identification of causative bacteria (OR 2.913) for below-average initial SF-36 were observed; leg weakness (OR 7.975) and WBC (OR 1.094) for below-average 6-month SF-36 were the statistically significant clinical factors in the multivariable logistic regression analysis (p < 0.05). Recurrence and leg weakness were identified as the most important clinical factors for medical burden and functional status in PSI, respectively. We think that it is necessary to actively suppress recurrence and manage neurological deficits for decreasing medical burden and achieving favorable functional outcome in the treatment of PSI.

Pyogenic spinal infections warrant a total spine MRI.

Study design: retrospective case series. Objective: the presenting clinical symptoms of spinal infections are often nonspecific and a delay in diagnosis can lead to adverse patient outcomes. The morbidity and mortality of patients with multifocal spinal infections is significantly higher compared to unifocal infections. The purpose of the current study was to analyse the risk factors for multifocal spinal infections. Methods: we conducted a retrospective review of all pyogenic non-tuberculous spinal infections treated surgically at a single tertiary care medical center from 2006-2020. The medical records, imaging studies, and laboratory data of 43patients during this time period were reviewed and analysed after receiving Institutional Review Board approval. Univariate and multivariate analyses were performed to identify factors associated with a multifocal spinal infection. Results: 15 patients (35 %) had multifocal infections. In univariate analysis, there was a significant association with chronic kidney disease ( ), gender ( ), a white blood cell count ( ), and cervical ( ) or thoracic ( .001) involvement. In multivariate analysis, both cervical and thoracic involvement remained statistically significant ( and , respectively). Conclusions: patients with infections in the thoracic or cervical region are more likely to have a multifocal infection. Multifocal pyogenic spinal infections remain a common entity and a total spine MRI should be performed to aid in prompt diagnosis.

Conservative or surgical treatment of pyogenic spinal infection. A retrospective multicenter binational retrospective cohort study.

Conservative or surgical treatment of pyogenic spinal infection. A retrospective multicenter binational retrospective cohort study.

Conservative or surgical treatment of pyogenic spinal infection. A retrospective multicenter binational retrospective cohort study

Conservative or surgical treatment of pyogenic spinal infection. A retrospective multicenter binational retrospective cohort study

Adult Pyogenic Spinal Infections

Adult Pyogenic Spinal Infections

Better Comprehension of Primary Pyogenic Spinal Infections.

To the Editor: Some years ago, childhood spondylodiscitis was used to describe a continuum of primary pyogenic spinal infections (PPSIs), from discitis to vertebral osteomyelitis, including spondylodiscitis with its occasional associated soft-tissue abscesses. The pathophysiology of PPSIs has, nevertheless, become clearer and less controversial. The theory suggesting that spondylodiscitis was a self-limiting inflammatory condition is now considered completely obsolete. A better understanding of pathophysiological processes has made it possible to differentiate forms of childhood PPSI according to patients’ ages, their immune system development, better knowledge of their bacterial etiology, and the vascularization of their vertebrae and disks. The different clinical forms of PPSI have now been categorized in various ways that physicians and pediatricians should know. The first classification is based on the child’s age and the development of their immune system, and it distinguishes three main clinical forms of childhood PPSI. The neonate form of spondylodiscitis generally affects infants under 6 months old and is recognized as the most severe manifestation of the disease: patients often present with septicemia and multiple infectious foci. Fortunately, this is the rarest form of the disease. The infantile form concerns children from 6 to 48 months old (a period during which maternally derived immunity decreases and stops), the age group representing 60%–80% of cases of childhood spondylodiscitis. Finally, in the third form, affecting children above 4 years old, patients are more prone to being febrile and appearing very ill. The second classification can be superimposed on the first and assigns each age group a bacterial probability of spondylodiscitis. Approximately 80% of spondylodiscitis cases in children younger than 6 months are due to S. aureus. For children from 6 to 48 months old, there are now robust arguments supporting the hypothesis that K. kingae should be considered the primary etiological pathogen for spondylodiscitis. The third form affects children older than 4 years of age, and S. aureus is the predominant pathogen. Finally, a third classification is based on the anatomical characteristics of the patient’s vertebral endplate and disk vascularization. Many studies have demonstrated that the vertebral endplates and the superficial portion of the disks share a common blood supply at birth that gradually regresses during infancy. In children, the metaphysis of the vertebral body has a rich blood flow, with an incomplete vascular ring ending at the pedicle’s base. Otherwise, it has been shown that several fine anastomotic branches exist between the upper and lower metaphyseal rings of two adjacent vertebrae, mostly present around the disk’s posterolateral region, providing its blood flow. It is also commonly accepted that infection starts under the vertebral endplates, that it subsequently and successively crosses both the vertebral endplate and the disk’s surface via those fine anastomotic branches, reaching the adjacent vertebral body and, lastly, the disk space between the two affected vertebral bodies. Interestingly, the blood vessels which cross the vertebral endplates evolve at around 7 or 8 years old. These anatomical observations lead to two conclusions. First, it becomes reasonable to think that pure discitis, as some authors have suggested, cannot occur. Secondly, it seems highly likely that children will tend to have spondylodiscitis before the age of 7 to 8 years old and, afterwards, that older children and adolescents are more likely to develop vertebral osteomyelitis, providing that the infection is not neglected. Unfortunately, these concepts do not yet appear in textbooks or university curricula, thus perpetuating enormous confusion about these infections.

Neutrophil–lymphocyte ratio as a potential marker for differential diagnosis between spinal tuberculosis and pyogenic spinal infection

ObjectiveDistinguishing spinal tuberculosis and pyogenic spinal infection is extremely important. The neutrophil–lymphocyte ratio (NLR), a simple indicator, has been shown to be a novel inflammatory marker. The objective of our study was to determine whether the NLR could be a potential indicator for discriminating spinal tuberculosis (STB) from pyogenic spinal infection (PSI).MethodsWe compared the clinical and laboratory characteristics of 146 patients diagnosed with STB and 60 participants with PSI from the First Affiliated Hospital of Nanjing Medical University. The NLR's diagnostic ability for differential diagnosis was assessed and compared to other hematological indicators, including the platelet–lymphocyte ratio (PLR).ResultsThe NLR in STB patients was considerably lower than that in PSI patients [3.85 (2.70–5.71) vs. 10.82 (6.79–17.62), P < 0.001]. An NLR of 6.742 was proposed as an optimal cutoff value for distinguishing patients with STB from those with PSI (sensitivity 78.33%, specificity 83.56%). However, the NLR's area under the curve [0.87, 95% confidence interval (CI) 0.81–0.92] was considerably higher than that of the PLR (0.73, 95% CI 0.65–0.80; P < 0.0001).ConclusionNLR levels could be a valuable laboratory diagnostic for distinguishing patients with STB from those who have PSI.

Spinal infection with intraspinal abscess or empyema and acute myelopathy: comparative analysis of diagnostics, therapy, complications and outcome in primary care

IntroductionThis study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account.MethodsPatients were enrolled in an ambispective study (2012–2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan–Meier method and Cox regression.ResultsIn total, 134 patients with a median (IQR) age of 72 (61–79) years were analyzed. Baseline characteristics were similar between the SCI (n = 55) and noSCI (n = 79). A higher percentage of endocarditis (9% vs. 0%; p = 0.03) was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group (e.g., urinary tract infection, pressure ulcers). Lethality risk factors were age (HR 1.09, 95% CI 1.02–1.16, p = 0.014), and empyema/abscess extension (≥ 3 infected spinal segments, HR 4.72, 95% CI 1.57–14.20, p = 0.006), dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%.ConclusionPSI + are associated with higher in-hospital mortality, particularly when multiple spinal segments are involved. However, survival is similar with (SCI) or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates.

Imaging characteristics and CT sensitivity for pyogenic spinal infections

Background/objectiveContrast-enhanced magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing pyogenic spinal infection (PSI), but it is not always available. Our objective was to describe pyogenic spinal infection imaging characteristics in patients presenting to a community emergency department (ED) and estimate the computed tomography (CT) sensitivity for these infections. MethodsWe examined the MRI reports from a cohort of 88 PSI patients whom we enrolled in a prospective cohort study and report the prevalence of each PSI type (spinal epidural abscess/infection, vertebral osteomyelitis/discitis, septic facet, and paravertebral abscess/infection) according to contemporary nomenclature. In a 14 patient subcohort who underwent both CT and MRI studies, we report the sensitivity for each PSI from a post hoc blinded overread of the CT imaging by a single neuroradiologist. ResultsOf the 88 PSI patients, the median age was 55 years, and 31% were female. The PSI prevalence included: spinal epidural abscess/infection (SEA) in 61(69%), vertebral osteomyelitis/discitis (VO/D) in 54 (61%), septic facet (SF) in 15 (17%), and paravertebral abscess/infection (PVA) in 53 (60%). Of the SEAs, 82% (50/61) were associated with other spinal infections, while 18% (11/61) were isolated SEAs. The overall CT sensitivity in a masked overread was 79% (11/14) for any PSI, 83% (10/12) for any infection outside the spinal canal, and only 18% (2/11) for SEA. ConclusionPatients found to have vertebral osteomyelitis/discitis, septic facet, and paravertebral infections frequently had a SEA coinfection. CT interpretation by a neuroradiologist had moderate sensitivity for infections outside the spinal canal but had low sensitivity for SEA.

Preoperative hypoalbuminemia and dialysis increase morbidity/mortality after spine surgery for primary pyogenic spinal infections (ACS-NSQIP Study).

Background: We analyzed the role of hypoalbuminemia, dialysis, and other risk factors that increase morbidity/ mortality following surgery for primary pyogenic spinal infections (PSIs). The American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) that included 627 patients was utilized as our database.Methods: Primary spinal surgery for spondylodiscitis was evaluated in a ACS-NSQIP database involving 627 patients between 2010 and 2019. Outcome assessment included evaluation of 30-day postoperative morbidity, and mortality rates.Results: Within 30 postoperative days, complications occurred in 14.6% (92/627) of patients; 59 (9.4%) required readmission, and 39 (6.2%) required additional surgery. The most common complications were: wound infections, pneumonia, septic shock, and death (1.8%). Hypoalbuminemia (i.e., significantly associated with unplanned readmission and reoperation), and dialysis were the two major risk factors contributing to increased perioperative morbidity and mortality.Conclusion: Among 627 ACS-NSQIP patients undergoing primary surgery for PSIs, hypoalbuminemia and dialysis were associated with higher risks of major perioperative morbidity (i.e., within 30 postoperative days – mostly readmissions and reoperations) and mortality.

An inter- and intra-rater agreement assessment of a novel classification of pyogenic spinal infections.

Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification. Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (wκ) to establish the inter- and intra-observer agreement. The inter-observer agreement was substantial considering the main categories (wκ = 0.77; 0.71-0.82), but moderate considering the subtypes (wκ = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (wκ = 0.65; 0.59-0.71), and moderate considering the subtypes (wκ = 0.58; 0.54-0.63). The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate.

A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection.

IntroductionPatients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions.MethodsWe conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool.ResultsIn the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38–70 and 51.5 (42–59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100–100%); 56% (95% CI, 48–64%), and 40% (95% CI, 36–46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829–0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84–98%), and 98% (95% CI, 94–100%), respectively.ConclusionThe SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.

The NIMS framework: an approach to the evaluation and management of epidural abscesses

Among the different types of spinal infections, spinal epidural abscesses (SEAs) pose a particular diagnostic and management challenge due to their close proximity to the thecal sac, potential for neurologic compromise, and close association with other spinal infections such as adjacent osteomyelitis, diskitis, or septic facet arthritis [ [1] Hadjipavlou AG Mader JT Necessary JT Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000; 25: 1668-1679 Crossref PubMed Scopus (495) Google Scholar ]. While early reports on SEA stressed the importance of urgent surgical decompression, the popularity of nonoperative treatment for epidural abscesses has risen, with multiple studies having endeavored to predict failure of nonoperative management of epidural abscesses [ 2 Shah AA Ogink PT Nelson SB Harris MB Schwab JH. Nonoperative Management of Spinal Epidural Abscess: Development of a Predictive Algorithm for Failure. J Bone Joint Surg Am. 2018; 100: 546-555 Crossref PubMed Scopus (19) Google Scholar , 3 Shah AA Ogink PT Harris MB Schwab JH. Development of Predictive Algorithms for Pre-Treatment Motor Deficit and 90-Day Mortality in Spinal Epidural Abscess. J Bone Joint Surg Am. 2018; 100: 1030-1038 Crossref PubMed Scopus (14) Google Scholar , 4 Karhade AV Shah AA Bono CM Ferrone ML Nelson SB Schoenfeld AJ et al. Development of machine learning algorithms for prediction of mortality in spinal epidural abscess. Spine J. 2019; 19: 1950-1959 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar , 5 Du JY Schell AJ Kim CY Trivedi NN Ahn UM Ahn NU. 30-day Mortality Following Surgery for Spinal Epidural Abscess: Incidence, Risk Factors, Predictive Algorithm, and Associated Complications. Spine (Phila Pa 1976). 2019; 44: E500-E5E9 Crossref PubMed Scopus (13) Google Scholar , 6 Kim SD Melikian R Ju KL Zurakowski D Wood KB Bono CM et al. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014; 14: 1673-1679 Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar ].

The Added Value of Cerebral Imaging in Patients With Pyogenic Spinal Infection.

Background: The incidence of pyogenic spinal infection has increased in recent years. In addition to treatment of the spinal infection, early diagnosis and therapy of coexisting infections, especially of secondary brain infection, are important. The aim of this study is to elucidate the added value of routine cerebral imaging in the management of these patients.Methods: This was a retrospective single-center study. Cerebral imaging consisting of cerebral magnetic resonance imaging (cMRI) was performed to detect brain infection in patients with a primary pyogenic spinal infection.Results: We analyzed a cohort of 61 patients undergoing cerebral imaging after diagnosis of primary pyogenic spinal infection. The mean age in this cohort was 68.7 years and the gender distribution consisted of 44 males and 17 females. Spinal epidural abscess was proven in 32 (52.4%) patients. Overall positive blood culture was obtained in 29 (47.5%) patients, infective endocarditis was detected in 23 (37.7%) patients and septic condition at admission was present in 12 (19.7%) Patients. Coexisting brain infection was detected in 2 (3.3%) patients. Both patients revealed clinical signs of severe sepsis, reduced level of consciousness (GCS score 3), were intubated, and died due to multi-organ failure.Conclusions: Brain infection in patients with spinal infection is very rare. Of 61 patients with pyogenic spinal infection, two patients had signs of cerebral infection shown by imaging, both of whom were in a coma (GCS 3), and sepsis.