Pyogenic Spondylodiscitis Research Articles

Hematologic Inflammation Indices for Differentiating between Brucella, Pyogenic, and Tuberculous Spondylodiscitis.

Infectious spondylodiscitis is a life-threatening disease and has some challenges in terms of diagnostic, differentiative, and therapeutic processes. Therefore, rapid and effective management of infectious spondylodiscitis is necessary. Hematological inflammation indices (HIIs) such as the neutrophil/lymphocyte ratio and aggregate index of systemic inflammation are derived from blood cells and used as diagnostic, prognostic, predictive, and treatment monitoring indicators. This study aimed to evaluate HIIs for discriminating between infectious spondylodiscitis pathogens. This retrospective comparative study included 116 patients with infectious spondylodiscitis. According to the responsible infectious pathogens, three types of infectious spondylodiscitis were defined: Brucella (n = 51), pyogenic (n = 43), and tuberculous (n = 22). The HIIs were derived from baseline complete blood counts. The three types of infectious spondylodiscitis were statistically compared for the HII scores. We found that the Brucella group had significantly lower HII scores than the pyogenic group (p < 0.05). Also, the Brucella group had significantly lower HII scores than the tuberculous group (p < 0.05). However, no significant differences were found between the pyogenic and tuberculous groups regarding HIIs (p > 0.05). In conclusion, the HIIs may be considered in the differentiation between Brucella spondylodiscitis and other types of infectious spondylodiscitis.

Clinical efficacy of one-stage anterior debridement and bone graft fusion for the treatment of cervical pyogenic spondylodiscitis

Objective: To investigate the efficacy of one-stage anterior debridement and bone graft fusion for the treatment of cervical pyogenic spondylodiscitis. Methods: This is a retrospective case series study. Retrospective analysis of clinical data from 23 patients with cervical pyogenic spondylodiscitis treated with one-stage anterior approach debridement and bone graft fusion was performed in the Department of Spinal Surgery, the First Affiliated Hospital of Xinjiang Medical University from January 2015 to January 2020. There were 14 males and 9 females,aged (51.9±12.8) years (range:26 to 82 years). Preoperatively, 14 patients had neurological deficits, classified according to the American Spinal Injury Association (ASIA) impairment scale as follows: grade A in 1 case, grade B in 1 case, grade C in 5 cases, and grade D in 7 cases. All patients underwent the one-stage anterior debridement and fusion procedure. The surgical time, blood loss, hospital stay, fusion time, and surgical complications were documented. Clinical efficacy was assessed using the visual analogue scale (VAS), the neck disability index (NDI), and the ASIA impairment scale. Preoperative and postoperative data were compared using paired sample t tests, repeated measures analysis of variance, and generalized estimating equations. Results: All the 23 patients underwent the operative procedures successfully. The operation time was (102.8±19.8) minutes (range:60 to 140 minutes), blood loss was (84.4±40.2) ml (range:30 to 160 ml), and the length of hospital stay was (17.4±6.0) days (range:10 to 30 days). Blood cultures were positive for the causative pathogen in 14 cases (60.8% positivity rate), while 9 cases had negative results. Irrigation fluid cultures yielded the causative pathogen in 19 cases (82.6% positivity rate), with 4 cases negative. All patients were followed up for more than 12 months, with a follow-up duration of (19.0±5.9) months (range:12 to 36 months). At the final follow-up, VAS improved from (5.9±1.1) points preoperatively to (0.8±0.3) points; NDI improved from (38.3±6.0)% preoperatively to (9.3±3.0)%, with statistically significant differences (both P<0.01). All patients experienced improvement in neurological function, with the exception of one patient in grade C and two in grade D, all other patients recovered to grade E. The C2-7 Cobb angle and the affected segment Cobb angle were corrected. white blood cell, erythrocyte sedimentation rate and C-reactive protein levels returned to normal. All patients achieved bony fusion, with a fusion time of (8.9±1.9) months (range:6 to 12 months). Two diabetic patients developed postoperative incision infection; no other surgery-related complications occurred in the remaining patients. Conclusion: One-stage anterior debridement and bone graft fusion can correct kyphosis, restore normal alignment, and improve neurological function in the treatment of single and double segment cervical pyogenic spondylodiscitis, representing a viable treatment option for cervical pyogenic spondylodiscitis.

Biofilm formation of Staphylococcus aureus on various implants used for surgical treatment of destructive spondylodiscitis

The incidence of spondylodiscitis has witnessed a significant increase in recent decades. Surgical intervention becomes necessary in case of bone destruction to remove infected tissue and restore spinal stability, often involving the implantation of a cage. Despite appropriate treatment, relapses occur in up to 20 percent of cases, resulting in substantial economic and social burdens. The formation of biofilm has been identified as a major contributor to relapse development. Currently, there is no consensus among German-speaking spinal surgeons or in the existing literature regarding the preferred choice of material to minimize relapse rates. Thus, the objective of this study is to investigate whether certain materials used in spinal implants exhibit varying degrees of susceptibility to bacterial attachment, thereby providing valuable insights for improving treatment outcomes.Eight cages of each PEEK, titanium-coated PEEK (Ti-PEEK), titanium (Ti), polyetherketoneketone (PEKK), tantalum (Ta) and antibiotic-loaded bone cement were incubated with 20% human plasma for 24 h. Subsequently, four implants were incubated with S. aureus for 24 h or 48 h each. The biofilm was then removed by sonication and the attained solution plated for Colony Forming Units (CFU) counting. Scanning electron microscopy was used to confirm bacterial attachment. The CFUs have been compared directly and in relation to the cages surface area. The surface area of the implants was PEEK 557 mm2, Ti-PEEK 472 mm2, Ti 985 mm2, PEKK 594 mm2, Ta 706 mm2, bone cement 123 mm2. The mean CFU count per implant and per mm2 surface area after 24 h and after 48 h was calculated. Bone cement was found to have significantly more CFUs per mm2 surface area than the other materials tested. When comparing the CFU count per implant, bone cement was statistically significantly more prone to biofilm formation than PEEK after 48 h. There was no statistical significance between the other materials when comparing both CFU count per mm2 surface area and CFU count per implant. The electron microscopic analysis showed the attachment of the bacteria, as well as production of extracellular polymeric substances (EPS) as a sign for beginning biofilm formation. Antibiotic-loaded bone cement has shown statistically significantly more bacterial attachment than the other examined materials. No difference was found between the other materials regarding bacterial attachment after 24 h and 48 h. Proposed hypotheses for further studies include testing whether differences become apparent after longer incubation or with different pathogens involved in the pathogenesis of pyogenic spondylodiscitis.

Idiopathic pyogenic thoracic and lumbar spondylodiscitis: outcome of long segment fixation

BackgroundSpondylodiscitis is an infection of the vertebral body extending to the intervertebral disc, and possibly the surrounding paraspinal structures.ObjectivesTo evaluate the clinical results of posterior long segment transpedicular screws fixation and decompression of the infected area for management of idiopathic pyogenic spondylodiscitis of the thoracic and lumbar spine.MethodsThis retrospective study included 14 patients with idiopathic active pyogenic spondylodiscitis of the lumber and thoracic spine between January 2017 and December 2021, with follow-up continuing until December 2022. All patients had posterior long-segment rigid fixation with infection decompression.ResultsAll patients after 6-month follow-up had achieved complete fusion. There was no evidence of postoperative wound infection, and no patient had a recurrence of infection at the lesion site during follow-up. Prior to surgery, the mean VAS score for back pain was 7.6 (range 6–9), however, after surgery, it fell to 1.3 (0–3), a statistically significant improvement (P < 0.001) during the last follow-up. According to the Kirkaldy-Willis criteria, the functional prognosis was excellent in 11 individuals, good in two, and fair in one.ConclusionsPosterior long-segment fixation in conjunction with decompression of the affected area effectively resolved bacterial spinal infection and restored neurological impairment.

A diagnostic model for differentiating tuberculous spondylodiscitis from pyogenic spondylodiscitis based on pathogen-confirmed patients.

This study aimed to distinguish tuberculous spondylodiscitis (TS) from pyogenic spondylodiscitis (PS) based on laboratory, magnetic resonance imaging (MRI) and computed tomography (CT) findings. Further, a novel diagnostic model for differential diagnosis was developed. We obtained MRI, CT and laboratory data from TS and PS patients. Predictive models were built using binary logistic regression analysis. The receiver operating characteristic curve was analyzed. Both internal and external validation was performed. A total of 81 patients with PS (n = 46) or TS (n = 35) were enrolled. All patients had etiological evidence from the focal lesion. Disc signal or height preservation, skip lesion or multi segment (involved segments ≥ 3) involvement, paravertebral calcification, massive sequestra formation, subligamentous bone destruction, bone erosion with osteosclerotic margin, higher White Blood Cell Count (WBC) and positive result of tuberculosis infection T cell spot test (T-SPOT.TB) were more prevalent in the TS group. A diagnostic model was developed and included four predictors: WBC<7.265 * (10^9/L), skip lesion or involved segments ≥ 3, massive sequestra formation and subligamentous bone destruction. The model showed good sensitivity, specificity, and total accuracy (91.4%, 95.7%, and 93.8%, respectively); the area under the receiver operating characteristic curve (AUC) was 0.981, similar to the results of internal validation using bootstrap resampling (1000 replicates) and external validation set, indicating good clinical predictive ability. This study develop a good diagnostic model based on both CT and MRI, as well as laboratory findings, which may help clinicians distinguish between TS and PS.

Lateral Approach With and Without Posterior Stabilization for Lumbar Pyogenic Spondylodiscitis Treatment: A Retrospective Study With an Average Follow-up of 7 Years

Objective: The aim of this study was to present the results after an average of 7-year follow-up in patients diagnosed with pyogenic spondylodiscitis (PS) treated with lumbar discectomy and fusion through minimally invasive lateral lumbar interbody fusion (LLIF), with and without posterior stabilization.Methods: In this retrospective analysis, patients diagnosed with PS treated with minimally invasive LLIF were studied. Variables included C-reactive protein (CRP), blood cultures, and findings on magnetic resonance imaging, computed tomography, and x-ray examinations. The classification of PS according to Pola was recorded.Results: Twenty-one patients were male (70%) and 9 were female (30%), with an average age of 67.6 years (range, 33–85 years). The average follow-up was 83.2 months (range, 12–160 months). In 7 out of the 30 cases, treatment consisted exclusively of discectomy and anterior fusion through LLIF. Bone consolidation was observed in 27 out of 30 cases (90%), with an average postoperative CRP level of 5.77±5.00 mg/L at the end of follow-up.Conclusion: The treatment of lumbar PS through debridement and minimally invasive LLIF, with or without posterior stabilization, resulted in infection control over an average follow-up of 83 months.

Minimally Invasive versus Traditional Surgery: Efficacy of PELD and PLIF in Treating Pyogenic Spondylodiscitis.

BACKGROUND Pyogenic spondylodiscitis is infection of the intervertebral disc or discs and the adjacent vertebrae. This retrospective study aimed to compare the effectiveness of percutaneous endoscopic lumbar debridement (PELD) versus posterior lumbar interbody fusion (PLIF) in 40 patients with pyogenic spondylodiscitis (PSD). MATERIAL AND METHODS Medical records of patients who underwent PELD (n=18) or PLIF (n=22) for PSD between 2018 and 2023 were reviewed. The recorded outcomes encompassed surgical duration, intraoperative blood loss, Oswestry Disability Index (ODI) measurements, Visual Analog Scale (VAS) assessments, C-reactive protein (CRP) levels, duration of hospitalization, erythrocyte sedimentation rate (ESR), American Spinal Injury Association (ASIA) grading, lumbar sagittal parameters, and the incidence of complications. RESULTS The PELD group had shorter surgical duration, less intraoperative blood loss, and shorter length of hospital stay compared to the PLIF group (P<0.01). At the last follow-up, both groups had significant improvement in ESR, CRP levels, and ASIA classification (P<0.001), but there was no significant difference between the 2 groups (P>0.05). The PELD group had lower ODI and VAS ratings at 1 month and 3 months, respectively (P<0.01). The PLIF group had significant improvements in intervertebral space height and lumbar lordosis angle (P<0.01). CONCLUSIONS Both PLIF and PELD surgical approaches demonstrate adequate clinical efficacy in the treatment of monosegmental PSD. PLIF can better ensure more spinal stability than PELD, but PELD offers advantages such as reduced minimal surgical trauma, shorter operative duration, and faster recovery after surgery.

Clinical and Radiological Features of Pyogenic and Brucellar Spondylodiscitis

Aim: Since spondylodiscitis continues to be seen with increasing incidence; thus, starting antibiotherapy targeted towards the etiological agent is crucial for reducing complications and mortality. This study aimed to determine the clinical and radiological characteristics of spondylodiscitis’ causative microorganisms. Material and Methods: Patients hospitalized in the Department of Infectious Diseases and Clinical Microbiology with a diagnosis of spondylodiscitis between 2015 and 2023 were retrospectively evaluated. Results: Low back pain was present in 97.5% of the total 40 patients as the most common symptom. Tissue biopsy culture results were obtained for 21 (52.5%) patients, with culture positivity observed in five (12.5%) patients. Consumption of raw milk/dairy products in the anamnesis and fever were found to be statistically significantly higher in patients with brucellosis (p &lt; 0.001, p = 0.015), whereas neurological deficits were significantly higher in the pyogenic group (p = 0.007). No significant differences were observed between the pyogenic and brucella spondylodiscitis groups in terms of laboratory parameters (sedimentation rate, C-reactive protein, white blood cell count) and magnetic resonance imaging findings. Conclusion: Since no distinctive clinical and radiological parameters were identified for distinguishing between brucellar and pyogenic spondylodiscitis, serological tests for brucellosis should be investigated when considering the diagnosis, particularly in endemic regions. In cases of pyogenic spondylodiscitis, empirical antibiotic use prior to pathogen isolation may lead to delays in diagnosis and appropriate treatment, potentially resulting in complications such as neurological deficits. Therefore, interventional methods for tissue biopsy culture should be planned before antibiotherapy, especially in patients who do not immediately require antibiotherapy.

A Comparative Factor Analysis and New Magnetic Resonance Imaging Scoring System for Differentiating Pyogenic Versus Tuberculous Spondylodiscitis.

This study aimed to compare and analyze differences in clinical and magnetic resonance imaging (MRI) findings between tuberculous spondylodiscitis (TbS) and pyogenic spondylodiscitis (PyS), and to develop and validate a simplified multiparameter MRIbased scoring system for differentiating TbS from PyS. We compared predisposing factors in 190 patients: 123 with TbS and 67 with PyS, confirmed by laboratory tests, culture, or pathology. Data encompassing patient demographics, clinical characteristics, laboratory results, and MRI findings were collected between 2015 and 2020. Data were analyzed using logistic regression methods, and selected coefficients were transformed into an MRI-based scoring system. Internal validation was performed using bootstrapping method. Univariate analysis revealed that the significant risk factors associated with TbS included thoracic lesions, vertebral destruction > 50%, intraosseous abscess, thin-walled abscess, well-defined paravertebral abscess, subligamentous spreading, and epidural abscess. Multivariate analysis revealed that only thoracic lesions, absence of epidural phlegmon, subligamentous spreading, intraosseous abscesses, well-defined paravertebral abscesses, epidural abscesses, and absence of facet joint arthritis were independent predictive factors for TbS (all p < 0.05). These potential predictors were used to derive an MRI scoring system. Total scores ≥ 14/29 points significantly predicted the probability of TbS, with a sensitivity of 97.58%, specificity of 92.54%, and an area under the curve of 0.96 (95% confidence interval, 125.40-3,257.95). This simplified MRI-based scoring system for differentiating TbS from PyS helps guide appropriate treatment when the causative organism is not identified.

Management of spontaneous pyogenic spondylodiscitis: a descriptive cohort study

BackgroundSpontaneous spondylodiscitis (SD) is an inflammation of the vertebral endplate and the intervertebral disc with no prior surgery or intervention. The treatment of spontaneous pyogenic SD mainly consists of systemic antibiotics and rest. Some cases require surgery due to failure of medical treatment or due to neurological compromise. Due to the disease heterogeneity, there are no standardized, widely adopted treatment protocols. We conducted this study to assess the clinical outcome of the different treatment modalities.ResultsThis is a retrospective analysis of prospectively collected data of patients with spontaneous non-tuberculous spondylodiscitis. Thirty-eight patients were identified, including 14 males and 24 females. The mean age was 49 years. Twenty-three patients underwent surgery from the start while 15 patients received conservative medical treatment. Among the latter, 8 patients showed disease progression and required surgical intervention. The ODI/NDI at 1 year (mean = 8) was significantly better than before treatment (mean = 18). Among 11 patients with motor deficit at presentation, 8 improved and 3 remained stable. There were 14 complications, including 11 minor and 3 major, requiring one revision surgery.ConclusionsSurgical decompression and debridement with or without instrumented fusion for complicated SD cases is a safe and effective treatment modality. Close follow-up is needed in case of conservative treatment for early detection of treatment failure and disease progression. Baseline characteristic variabilities in patients with spontaneous pyogenic SD could predict conservative treatment failure, but this needs to be validated in larger series.

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

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

Free Vascularized Fibula Graft as Primary Salvage Procedure for Acute Cervical Osteomyelitis Caused by Epidural Abscess.

Acute cervical osteomyelitis due to an epidural abscess and pyogenic spondylodiscitis in an immunosuppressed patient with progressive myelopathy is a challenge for the reconstructive surgeon. This report presents our novel approach to treat such a condition in a 56-year-old patient in whom antibiotic treatment and decompression of the medulla by laminectomy of C4-C6 failed. Under general anesthesia, debridement of all infected tissue, including anterior corpectomy of C4-C6, was performed. Simultaneously, a free vascularized fibula graft (FVFG) was harvested, adapted to the bone defect, and anastomosed to the superior thyroid artery and external jugular vein. The graft was stabilized with an anterior plate. A scheduled posterior stabilization was performed 1 week later. Staphylococcus aureus was cultured from bone samples and was treated with antibiotics. The postoperative course was uncomplicated besides a dorsal midline defect 6 weeks postoperatively that was closed with a sensate midline-based perforator flap. Five years on, the patient is infection free, and regular control computed tomography and magnetic resonance imaging scan images show progressive fusion and hypertrophy of the fibula to C3/C7 vertebrae. An FVFG combined with posterior stabilization could be a promising primary salvage procedure in cases with progressive myelopathy caused by acute cervical osteomyelitis due to spinal infection. The FVFG contributes to blood circulation, delivery of antibiotics, and an immunological response to the infected wound bed and can stimulate rapid fusion and hypertrophy over time.

Variation of practice in the treatment of pyogenic spondylodiscitis: a European Association of Neurosurgical Societies Spine Section study.

The incidence of spondylodiscitis is rising across Europe, but the ideal treatment approach remains controversial. The choice between conservative and surgical therapies is ambiguous due to a lack of consensus. This European survey aimed to explore prevailing treatment paradigms for primary spondylodiscitis. Spine neurosurgeons were invited through the European Association of Neurosurgical Societies Spine Section's mailing list to participate in an online survey featuring 7 spondylodiscitis case vignettes. Along with general management queries, specific patient treatment questions were posed. Data analysis was performed using R software (version 4.0.4). The index of qualitative variation (IQV) was calculated to quantify the variability in responses. A total of 130 responses were collected, comprising 86.9% board-certified neurosurgeons and 13.1% neurosurgeons in training, with an average of 11 years of practice. Most respondents performed 50-100 spine surgeries annually, with 66.7% specializing in spine surgery. An epidural empyema causing pronounced neurological deficits influenced 95.4% toward a surgical intervention, and mild neurological deficits and challenges in pathogen identification prompted 72.3% and 80%, respectively, to consider a surgical approach. Vertebral body destruction and spinal deformity directed 60% and 66.2%, respectively, toward surgery, whereas advanced age and comorbidities had a much smaller impact-5.4% and 9.2%, respectively. Clinical vignettes highlighted a predominant preference for conservative treatment in specific cases, with statistical significance (p < 0.05). The IQV values evaluated for each question ranged from 0.88 to 0.99, indicating low agreement across all questions among respondents. When examining the average IQV by country, intercountry variations in IQV were substantial, as illustrated by the diverse range of overall mean IQV values (0.15-0.85). The findings reveal a significant variability in the treatment of spondylodiscitis among European neurosurgeons, with most neurosurgeons opting for conservative treatment. These diverse strategies, both between and within countries, highlight an imperative for evidence-backed guidelines and consensus statements for this grave condition.

Generation of synthetic PET/MR fusion images from MR images using a combination of generative adversarial networks and conditional denoising diffusion probabilistic models based on simultaneous 18F-FDG PET/MR image data of pyogenic spondylodiscitis

BACKGROUND CONTEXTCross-modality image generation from magnetic resonance (MR) to positron emission tomography (PET) using the generative model can be expected to have complementary effects by addressing the limitations and maximizing the advantages inherent in each modality. PURPOSEThis study aims to generate synthetic PET/MR fusion images from MR images using a combination of generative adversarial networks (GANs) and conditional denoising diffusion probabilistic models (cDDPMs) based on simultaneous 18F-fluorodeoxyglucose (18F-FDG) PET/MR image data. STUDY DESIGNRetrospective study with prospectively collected clinical and radiological data. PATIENT SAMPLEThis study included 94 patients (60 men and 34 women) with thoraco-lumbar pyogenic spondylodiscitis (PSD) from February 2017 to January 2020 in a single tertiary institution. OUTCOME MEASURESQuantitative and qualitative image similarity were analyzed between the real and synthetic PET/ T2-weighted fat saturation MR (T2FS) fusion images on the test data set. METHODSWe used paired spinal sagittal T2FS and PET/T2FS fusion images of simultaneous 18F-FDG PET/MR imaging examination in patients with PSD, which were employed to generate synthetic PET/T2FS fusion images from T2FS images using a combination of Pix2Pix (U-Net generator + Least Squares GANs discriminator) and cDDPMs algorithms. In the analyses of image similarity between the real and synthetic PET/T2FS fusion images, we adopted the values of mean peak signal to noise ratio (PSNR), mean structural similarity measurement (SSIM), mean absolute error (MAE), and mean squared error (MSE) for quantitative analysis, while the discrimination accuracy by three spine surgeons was applied for qualitative analysis. RESULTSTotal of 2,082 pairs of T2FS and PET/T2FS fusion images were obtained from 172 examinations on 94 patients, which were randomly assigned to training, validation, and test data sets in 8:1:1 ratio (1664, 209, and 209 pairs). The quantitative analysis revealed PSNR of 30.634 ± 3.437, SSIM of 0.910 ± 0.067, MAE of 0.017 ± 0.008, and MSE of 0.001 ± 0.001, respectively. The values of PSNR, MAE, and MSE significantly decreased as FDG uptake increased in real PET/T2FS fusion image, with no significant correlation on SSIM. In the qualitative analysis, the overall discrimination accuracy between real and synthetic PET/T2FS fusion images was 47.4%. CONCLUSIONSThe combination of Pix2Pix and cDDPMs demonstrated the potential for cross-modal image generation from MR to PET images, with reliable quantitative and qualitative image similarities.

Post-Discectomy Infection: A Critical Review and Suggestion of a Management Algorithm.

Postoperative discitis (POD) accounts for 20% to 30% of all cases of pyogenic spondylodiscitis, while POD may be mis-or-under-diagnosed, due to the vague related symptomatology and the non-specific imaging findings. Most studies report infection rate of less than 1%, which increases with the addition of non-instrumented fusion to 2.4% to 6.2%. It remains controversial whether POD is caused by an aseptic or infectious process. Positive cultures are presented only in 42-73% of patients with Staphylococcus species being the most common invading organisms, while Staphylococcus aureus is isolated in almost 50% of cases. The onset of POD symptoms usually occurs at 2-4 weeks after an apparently uneventful operation. Back pain and muscle spasms are usually refractory to bed rest and analgesics. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging diagnostic technique. Antimicrobial therapy depends on the results of tissue cultures, and along with bracing represents the mainstay of management. Surgical intervention is necessary in patients failing conservative treatment. For the majority of cases, extensive surgical debridement, antibiotic therapy, and orthosis immobilization are effective in eliminating the infection. According to this, we recommend an Algorithmic approach for the management of POD. Postoperative infections after spinal surgery pose a certain clinical challenge, and in most cases can be treated conservatively. Nevertheless, disability may be persistent, and surgery could be necessary. The purpose of this concise review is to describe the manifestation of post-discectomy infection, its pathogenesis and particularly a rational approach for its management.

A comparative perspective on brucellar, pyogenic, and tuberculous spondylodiscitis.

Non-specific features of spondylodiscitis lead to a delay and challenge in the diagnosis/differential diagnosis/treatment processes, and thus, serious complications may arise. This study aims to compare brucellar, pyogenic, and tuberculous types of spondylodiscitis, considering their demographic, clinical, and laboratory differences. This may provide more rapid management and good outcomes. A total of 131 patients with infectious spondylodiscitis were included in the study. The patients were divided into brucellar (n=63), pyogenic (n=53), and tuberculous (n=15) types of spondylodiscitis and compared for demographic, clinical, laboratory, and imaging features. Tuberculous spondylodiscitis had higher scores for weight loss, painless palpation, thoracic spine involvement, and psoas abscess formation than other spondylodiscitis. Also, tuberculous spondylodiscitis had higher rates of neurologic deficit and lower rates of lumbar involvement than brucellar spondylodiscitis. Pyogenic spondylodiscitis is more likely to occur in patients who have a history of spine surgery compared to other forms of spondylodiscitis. Also, pyogenic spondylodiscitis had higher rates of fever, erythema, paraspinal abscess, white blood cell (WBC), and erythrocyte sedimentation rate (ESR) than brucellar spondylodiscitis. On the other hand, brucellar spondylodiscitis had higher rates of rural living and sweating than pyogenic spondylodiscitis. Weight loss, painless palpation, involved thoracic spine, psoas abscess, and neurologic deficit are symptoms favoring tuberculous spondylodiscitis. History of spine surgery, high fever, skin erythema, and paraspinal abscess are findings in favor of pyogenic spondylodiscitis. Rural living, sweating, and involved lumbar spine are symptoms that indicate brucellar spondylodiscitis. These symptoms can be used to distinguish the types of spondylodiscitis.

Hemorrhagic Acalculous Cholecystitis in Pyogenic Spondylodiscitis Patient

Hemorrhagic cholecystitis (HC) is a rare form of cholecystitis that may be caused by the progression of either calculous or acalculous cholecystitis, which has been reported sporadically as case reports. Acalculous cholecystitis is often diagnosed late and can be fulminant. HC without gallstones also can have a poor prognosis and be linked to a high mortality rate. Therefore, early detection, hemodynamic monitoring, and prompt treatment are essential to treat bleeding in cholecystitis. We report a case of hemorrhagic acalculous cholecystitis discovered during the examination and point-of-care ultrasound in a patient with pyogenic spondylodiscitis. The patient was referred with a chief complaint of liver dysfunction without bleeding tendencies or risk factors. Ultrasound revealed focal gallbladder wall irregularity, intraluminal membranes, and non-shadowing non-layering intraluminal echoes. Extravascular contrast leakage was exhibited on the computed tomography scan. The patient underwent emergency percutaneous drainage and subsequent cholecystectomy before developing major complications.

The importance of the bacterial spectrum in the clinical diagnostics and management of patients with spontaneous pyogenic spondylodiscitis and isolated spinal epidural empyema: a 20-year cohort study at a single spine center

BackgroundPersonalized clinical management of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) is challenging due to limited evidence of microbiologic findings and their clinical impact during the clinical course of the disease. We aimed to characterize clinico-microbiological and imaging phenotypes of SD and ISEE to provide useful insights that could improve outcomes and potentially modify guidelines.MethodsWe performed chart review and collected data on the following parameters: bacterial antibiogram-resistogram, type of primary spinal infection, location of spinal infection, source of infection, method of detection, clinical complications (sepsis, septic embolism, and endocarditis), length of hospital and intensive care unit (ICU) stay, relapse rate, and disease-related mortality in patients with proven pyogenic SD and ISEE treated surgically in a university hospital in Germany between 2002 and 2022.ResultsWe included data from 187 patients (125 SD, 66.8% and 62 ISEE, 33.2%). Gram-positive bacteria (GPB) were overall more frequently detected than gram-negative bacteria (GNB) (GPB: 162, 86.6% vs. GNB: 25, 13.4%, p < 0.001). Infective endocarditis was caused only by GPB (GPB: 23, 16.5% vs. GNB: 0, 0.0%, p = 0.046). Methicillin-susceptible Staphylococcus aureus was the most frequently isolated strain (MSSA: n = 100, 53.5%), occurred more frequently in the cervical spine compared to other bacteria (OB) (MSSA: 41, 41.0% vs. OB: 18, 20.7%, p = 0.004) and was most frequently detected in patients with skin infection as the primary source of infection (MSSA: 26, 40.6% vs. OB: 11, 16.7%, p = 0.002). Streptococcus spp. and Enterococcus spp. (SE: n = 31, 16.6%) were more often regarded as the cause of endocarditis (SE: 8, 27.6% vs. OB: 15, 11.4%, p = 0.037) and were less frequently detected in intraoperative specimens (SE: 19, 61.3% vs. OB: 138, 88.5%, p < 0.001). Enterobacterales (E: n = 20, 10.7%) were identified more frequently in urinary tract infections (E: 9, 50.0% vs. OB: 4, 3.6%, p < 0.001). Coagulase-negative Staphylococci (CoNS: n = 20, 10.7%) were characterized by a lower prevalence of sepsis (CoNS: 4, 20.0% vs. OB: 90, 53.9%, p = 0.004) and were more frequently detected in intraoperative specimens (CoNS: 20, 100. 0% vs. OB: 137, 82.0%, p = 0.048). Moreover, CoNS-associated cases showed a shorter length of ICU stay (CoNS: 2 [1–18] days vs. OB: 6 [1–53] days, median [interquartile range], p = 0.037), and occurred more frequently due to foreign body-associated infections (CoNS: 8, 61.5% vs. OB: 15, 12.8%, p = 0.008). The presence of methicillin-resistant Staphylococcus aureus (MRSA) prolonged hospital stay by 56 [24–58] days and ICU stay by 16 [1–44] days, whereas patients with Pseudomonas aeruginosa spent only 20 [18–29] days in the hospital and no day in the ICU 0 [0–5] days.ConclusionsOur retrospective cohort study identified distinct bacterial-specific manifestations in pyogenic SD and ISEE regarding clinical course, neuroanatomic targets, method of pathogen detection, and sources of infection. The clinico-microbiological patterns varied depending on the specific pathogens.

Concomitant spinal and non-spinal osteoarticular infections

Abstract Background: Treatment of pyogenic spondylodiscitis or septic arthritis can be complicated with a variety of concomitant infectious processes. No study has focused on concomitant osteoarticular infections. Materials and Methods: Between 2015 and 2019, patients over 18 years old, who were diagnosed and treated for spinal infections (SIs) or non-spinal osteoarticular infections, were included. There were six patients with concomitant spinal and non-spinal osteoarticular infections (concomitant infection [CI] group), 30 patients with SI alone (SI group), and 18 patients with articular infection (AI) alone (AI group). The data gained from the patients in the CI group were compared those in the SI group and the AI group. Results: Factors contributing to statistical significance included past or present history of cancer (100% in the CI group, 27% in the SI group, and 33% in the AI group), C-reactive protein (CRP) levels (27.4 mg/dL in the CI group, 13.4 mg/dL in the SI group, and 13.8 mg/dL in the AI Group), albumin levels (2.4 g/dL in the CI group and 2.9 in both the SI group and the AI group), detection of Group B Streptococcus (GBS) (50% in the CI group, 3.3% in the SI group and 5.6% in the AI group), and duration of intravenous antibiotic therapy (131 days in the CI group, 67 days in the SI group and 29 days in the AI group). Conclusions: Patients with concomitant spinal and non-spinal osteoarticular infections were more likely to present with a past and present history of cancer, severe hypoalbuminemia, higher levels of CRP and GBS bacteremia.

Radiographic Progression and Spinal Deformity in Conservatively Treated Pyogenic Spondylodiscitis: A Monocentric, Retrospective Analysis of MRI Data from 59 Patients

Radiographic Progression and Spinal Deformity in Conservatively Treated Pyogenic Spondylodiscitis: A Monocentric, Retrospective Analysis of MRI Data from 59 Patients