Pyogenic Vertebral Osteomyelitis Research Articles

CORR Insights®: Are Dental Procedures Associated With Pyogenic Vertebral Osteomyelitis?

CORR Insights®: Are Dental Procedures Associated With Pyogenic Vertebral Osteomyelitis?

Are Dental Procedures Associated With Pyogenic Vertebral Osteomyelitis?

Dental procedures can lead to bacteremia and have been considered a potential risk factor for pyogenic vertebral osteomyelitis (PVO). However, data on the association between dental procedures and PVO are limited. (1) After controlling for relevant confounding variables, are dental procedures associated with an increased risk of PVO? (2) Does antibiotic prophylaxis before dental procedures effectively decrease the risk of PVO? A case-crossover study was conducted to investigate the association between dental procedures and PVO using a Japanese claims database. The advantage of this study design is that confounding factors that do not vary over time are automatically adjusted for, because cases act as their own controls. From April 2014 to September 2021, the database included 8414 patients who were hospitalized for PVO. Of these, 50% (4182 of 8414) were excluded because they had not undergone any dental procedures before the index date, a further 0.1% (10 of 8414) were excluded because they were younger than 18 years at the index date, and a further 7% (623 of 8414) were excluded because they did not have at least 20 weeks of continuous enrollment before the index date, leaving 43% (3599 of 8414) eligible for analysis here. The mean age was 77 ± 11 years, and 55% (1985 of 3599) were men. Sixty-five percent (2356 of 3599) of patients had a diagnosis of diabetes mellitus, and 42% (1519 of 3599) of patients had a diagnosis of osteoporosis. We compared the frequency of dental procedures between a 4-week hazard period before the admission date for PVO and two control periods, 9 to 12 weeks and 17 to 20 weeks before the admission date for PVO, within individuals. We calculated odds ratios and 95% confidence intervals using conditional logistic regression analysis. Comparing the hazard and matched control periods within individuals demonstrated that dental procedures were not associated with an increased risk of PVO (OR 0.81 [95% CI 0.72 to 0.92]; p < 0.001). Additional analysis stratified by antibiotic prophylaxis use showed that antibiotic prophylaxis was not associated with a lower OR of developing PVO after dental procedures (with antibiotic prophylaxis: OR 1.11 [95% CI 0.93 to 1.32]; p < 0.26, without antibiotic prophylaxis: OR 0.72 [95% CI 0.63 to 0.83]; p < 0.001). Our sensitivity analyses, in which the exposure assessment interval was extended from 4 to 8 or 12 weeks and exposure was stratified by whether the dental procedure was invasive, demonstrated results that were consistent with our main analysis. Dental procedures were not associated with an increased risk of subsequent PVO in this case-crossover study. The effectiveness of antibiotic prophylaxis was not demonstrated in the additional analysis that categorized exposure according to the use of antibiotic prophylaxis. Our results suggest that the association between dental procedures and PVO may have been overestimated. Maintaining good oral hygiene may be important in preventing the development of PVO. The indications for antibiotic prophylaxis before dental procedures should be reconsidered in view of the potential risk of adverse drug reactions to antibiotic prophylaxis and the emergence of drug-resistant pathogens. Larger randomized controlled trials are needed to confirm these findings and assess the role of antibiotic prophylaxis. Level III, therapeutic study.

DIAGNOSIS AND TREATMENT SPONDYLODISCITIS : THE LITERATURE REVIEW

In many regions of the globe, pyogenic spondylitis remains a significant concern. It is a disorder that affects a very small proportion of the population, but it can be quite severe and even fatal. Frequently, it is difficult to make a diagnosis due to the absence of evident signs or symptoms. It encompasses a vast array of clinical entities, including pyogenic spondylodiscitis, discitis, vertebral osteomyelitis, and spinal osteomyelitis, among others. The success rates of conservative treatment are comparable to those of surgical treatment, but complications and mortality rates are lower. In the absence of a clear indication for surgical intervention, conservative treatment should be considered first. Patients with cervical tract or tuberculous spondylodiscitis should endure closer diagnostic and clinical monitoring due to the increased risk of developing bone collapse and neurological deficits.

Risk Factors for the In-Hospital Mortality in Pyogenic Vertebral Osteomyelitis: A Cross-Sectional Study on 9753 Patients.

Pyogenic vertebral osteomyelitis represents a clinical challenge associated with significant morbidity and mortality. The aim of this study was to analyze potential risk factors for the in-hospital mortality of vertebral osteomyelitis (VO) patients. Based on the International Classification of Diseases, 10th Revision (ICD-10) codes for VO ("M46.2-", "M46.3-", and "M46.4-") data for total case numbers, secondary diagnoses, and numbers of in-hospital deaths were extracted from the Institute for the Hospital Remuneration System (InEK GmbH). Odds ratios (OR) for death were calculated for several secondary diseases and factors of interest. Despite age, certain comorbidities were found to be strongly associated with increased mortality risk: Heart failure (OR = 2.80; 95% CI 2.45 to 3.20; p < 0.01), chronic kidney disease (OR = 1.83; 95% CI 1.57 to 2.13; p < 0.01), and diabetes with complications (OR = 1.86; 95% CI 1.46 to 2.38; p < 0.01). Among the complications, acute liver failure showed the highest risk for in-hospital mortality (OR = 42.41; 95% CI 23.47 to 76.62; p < 0.01). Additionally, stage III kidney failure (OR = 9.81; 95% CI 7.96 to 12.08; p < 0.01), sepsis (OR = 5.94; 95% CI 5.02 to 7.03; p < 0.01), acute respiratory failure (OR = 5.31; 95% CI 4.61 to 6.12; p < 0.01), and systemic inflammatory response syndrome (SIRS) (OR = 5.19; 95% CI 3.69 to 5.19; p < 0.01) were associated with in-hospital mortality. When analyzing the influence of pathogens, documented infection with Pseudomonas aeruginosa had the highest risk for mortality (OR = 2.74; 95% CI 2.07 to 3.63; p < 0.01), followed by Streptococci, Escherichia coli, and Staphylococcus aureus infections. An early assessment of individual patient risk factors may be beneficial in the care and treatment of VO to help reduce the risks of mortality. These findings emphasize the importance of closely monitoring VO patients with chronic organ diseases, early detection and treatment of sepsis, and tailored empirical antibiotic therapy. The identification of specific pathogens and antibiotic susceptibility testing should be prioritized to improve patient outcomes in this high-risk population.

Effectiveness of oral cephalexin in antibiotic-course completion for methicillin-susceptible Staphylococcus aureus-induced bacteremic vertebral osteomyelitis

BackgroundMethicillin-susceptibleStaphylococcus aureus (MSSA) is the most common causative microorganism of pyogenic vertebral osteomyelitis (PVO). Although oral antimicrobial therapy with first-generation cephalosporins can treat MSSA infection, data on PVO are scarce. This study evaluated the treatment efficacy of cephalexin as oral antibiotic therapy for MSSA-induced PVO.MethodsThis retrospective study included adult patients treated with oral cephalexin as the completing treatment for PVO with MSSA bacteremia from 2012 to 2020. Treatment effectiveness of cephalexin was evaluated by comparing improvement (5-point scale; score ≥ 4/5 indicates treatment success) in symptoms and laboratory and imaging results between intravenous antimicrobial and oral cephalexin treatment.ResultsAmong 15 participants (8 [53%] women; median [interquartile range, IQR], age 75 [67.5–80.5] years; Charlson Comorbidity Index 2 [0–4]), 10 (67%) had lumbar spine lesions, 12 (80%) had spinal abscesses, and 4 (27%) had remote abscesses; no patients had concomitant endocarditis. In 11 patients with normal renal function, cephalexin 1,500–2,000 mg/day was administered. Five patients (33%) underwent surgery. Median (IQR; range) duration (days) of intravenous antibiotics, cephalexin, and total treatment was 36 (32–61; 21–86), 29 (19–82; 8–251), and 86 (59–125; 37–337), respectively. Cephalexin had an 87% treatment success rate without recurrence during a median follow-up of 119 (IQR, 48.5–350) days.ConclusionsIn patients with MSSA bacteremia and PVO, antibiotic treatment completion with cephalexin is a reasonable option, even in cases with spinal abscess, if at least 3 weeks of effective intravenous antimicrobial therapy is provided.

Mortality, complication risks, and clinical outcomes after surgical treatment of spinal epidural abscess: a comparative analysis of patients aged 18–64 years, 65–79 years, and ≥ 80 years, with a 3-year follow-up

Spinal epidural abscess (SEA) with pyogenic vertebral osteomyelitis (PVO) is a rare illness with a steadily increasing incidence. However, comparative analyses of young and older patients with SEA are lacking. We aimed to compare the clinical course of patients aged 18–64 years, 65–79 years, and ≥ 80 years undergoing surgery for SEA. Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Ninety-nine patients aged 18–64 years, 45 patients aged 65–79 years, and 32 patients ≥ 80 years were enrolled. Patients ≥ 80 years presented with a poorer baseline history (9.2 ± 2.4), as indicated by the CCI, than their younger counterparts (18–74 years: 4.8 ± 1.6;6.5 ± 2.5; p < 0.001). Patients aged 65–79 years and 80 years had a significantly longer length of stay. In-hospital mortality was significantly higher in those aged ≥ 80 years compared to their younger counterparts (≥ 80 years, n = 3, 9.4% vs. 18–64 years, n = 0, 0.0%; 65–79 years, n = 0, 0.0%; p < 0.001), while no differences in 90-day mortality or 30-day readmission were observed. After surgery, a significant decrease in C-reactive protein levels and leukocytes and amelioration of motor scores were observed in all the groups. Of note, older age (> 65 years), presence of comorbidities, and poor preoperative neurological condition were significant predictors of mortality. Surgical management led to significant improvements in laboratory and clinical parameters in all age groups. However, older patients are prone to multiple risks, requiring meticulous evaluation before surgery. Nevertheless, the risk profile of younger patients should not be underestimated. The study has the limitations of a retrospective design and small sample size. Larger randomized studies are warranted to establish the guidelines for the optimal management of patients from every age group and to identify the patients who can benefit from solely conservative management.

Long-term patient-related quality of life outcomes and ICD-10 symptom rating (ISR) of patients with pyogenic vertebral osteomyelitis: What is the psychological impact of this life-threatening disease?

PurposeWe aimed to evaluate the long-term impact of the treatment of pyogenic vertebral osteomyelitis (VO) on functional outcomes and patients' quality of life (QoL) with a special focus on psychological well-being.MethodsA total of 156 patients with VO with a minimum clinical follow-up of 12 months were retrospectively identified and asked to participate. Patient-reported outcome measures were evaluated with the EuroQol five-dimension questionnaire (EQ-5D) and German Short-Form 36 (SF-36) outcome instruments as well as with an ICD-10 based symptom rating (ISR) and compared to normative data. Spine-specific outcomes were assessed with the Core Outcome Measure Index and the Oswestry disability index (ODI) or the Neck disability index (NDI), respectively.ResultsFrom n = 156 eligible patients, n = 129 patients could be contacted and n = 40 returned questionnaires, yielding a response rate of 31.0%. The mean time from hospital discharge to follow-up was 83.0 ± 3.8 (13–193) months. Spine-specific outcomes showed mild to moderate disability. The mean physical health component score of the SF-36 (37.1 ± 16.7), the mean mental health component score (38.2 ± 14.0) and the mean EQ-5D VAS rating (57.1 ± 21.5) were significantly lower in comparison with the scores of an age-matched reference population (all p < 0.05). The mean total score of the ISR was 0.53 ± 0.23. On average, the cohort did not cross the threshold of clinically relevant symptom burden on any subscale.ConclusionEven almost seven years on average after completed treatment of VO, patients report impaired QoL. Assessment of psychological disorders should be implemented in clinical practice and future prospective studies.

978. Effectiveness of oral cephalexin as completing treatment for bacteremic vertebral osteomyelitis caused by Methicillin-susceptible Staphylococcus aureus

Abstract Background Methicillin-susceptible Staphylococcus aureus (MSSA) is the most common causative microorganism of pyogenic vertebral osteomyelitis (VO). Oral antimicrobial therapy with first-generation cephalosporins can treat MSSA infection, but data on pyogenic VO are scarce. Methods This retrospective study included adult patients treated with oral cephalexin as the completing treatment for pyogenic VO with bacteremia due to MSSA at the National Center for Global Health and Medicine Hospital, Japan from 2012 to 2020. Treatment effectiveness of cephalexin was evaluated by comparing the improvement in symptoms and laboratory and imaging results after intravenous (IV) administration of antimicrobial agents and after oral cephalexin treatment, using a 5-point scale (Table). A score of 4 or 5 indicated treatment success. Results This study included 15 patients (8 [53%] females), with median age 75 years (interquartile range [IQR], 67.5–80.5), median body weight 57.0 kg (IQR, 45.5–62.5), and median Charlson comorbidity index score 2 (IQR, 0–4). Ten patients (67%) had lesions in the lumbar spine. Six patients had lesions at multiple sites (cervical and thoracic, n=1; cervical and lumbar, n=2; thoracic and lumbar, n=1; and lumbar and sacral, n=2). Twelve patients (80%) had spinal abscesses and four (27%) had remote abscesses, but none had concomitant endocarditis. In 11 patients with normal renal function, 1,500–2,000 mg/day of cephalexin was administered. Surgical intervention was performed in five cases (33%). The median duration of IV antibiotics, cephalexin, and total treatment was 36 (IQR, 32–61; range, 21–86), 29 (IQR, 19–82; range, 8–251), and 86 (IQR, 59–125; range, 37–337) days, respectively. Majority patients (≥80%) received either cefazolin or ceftriaxone as IV therapy. Two patients used oral antimicrobials other than cephalexin outside of the cephalexin treatment period. Treatment success rate after cephalexin therapy was 87%. None of the patients had recurrence during a median follow-up of 119 days (IQR, 48.5-350). Conclusion In patients with bacteremic VO due to MSSA, completing treatment with cephalexin is a reasonable option, even in cases with spinal abscess, if at least 3 weeks of effective IV antimicrobial therapy is provided. Disclosures All Authors: No reported disclosures.

Life Expectancy Is Poor in Patients with Diffuse Idiopathic Skeletal Hyperostosis-Related Pyogenic Vertebral Osteomyelitis.

Pyogenic vertebral osteomyelitis (PVO) is an uncommon but life-threatening infectious disease. Diffuse idiopathic skeletal hyperostosis (DISH) is an age-related disorder and sometimes problematic in terms of spinal instability or high mortality, especially in cases of DISH-related fracture. Meanwhile, no reports have focused on the impact of DISH on the clinical outcomes after treatment for PVO. We hypothesized that PVO occurring at DISH-related segments might contribute to poor clinical results or high mortality rates. The purpose of this study was to investigate the impact of DISH on mortality after treatment for PVO in a retrospective cohort study. This study involved patients who were hospitalized and treated for PVO at a single institution. DISH-related PVO was defined as PVO within a segment ossified by DISH or PVO at the neighboring intervertebral level of the segment ossified by DISH. Differences in mortality between patients with DISH-related and non-DISH-related PVO were investigated. This study included 55 patients. DISH-related PVO was observed in 13 patients. The mortality rate was significantly higher in patients with DISH-related PVO than in those with non-DISH-related PVO (62% and 23%, respectively; p=0.016). Propensity score-adjusted analysis showed that DISH-related PVO was an independent risk factor for mortality (adjusted hazard ratio, 2.79; p=0.034). The survival probability was significantly shorter in patients with DISH-related PVO than in those with non-DISH-related PVO (p=0.006). PVO in which the intravertebral body was the center of involvement was significantly more common in DISH-related PVO than in non-DISH-related PVO (38% and 5%, respectively; p=0.006). DISH-related PVO was associated with a higher mortality rate and shorter life expectancy than non-DISH-related PVO. Similar to advanced age, PVO at the segment ossified by DISH should be recognized as a risk factor for mortality when choosing the optimal treatment strategy.

Surgical Management of Spinal Epidural Abscess in Elderly Patients: A Comparative Analysis Between Patients 65–79 Years and ≥80 Years with 3-Year Follow-Up

Recently, the incidence of pyogenic vertebral osteomyelitis with spinal epidural abscess (SEA) has increased. However, the most appropriate surgical management remains debatable, especially for older patients. This study aimed to compare the clinical course in older patients aged between 65 and 79 years and those 80 years or older undergoing surgery for SEA. Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality of patients diagnosed with pyogenic vertebral osteomyelitis and SEA between September 2005 and December 2021 were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index. We enrolled 45 patients aged 65-79 years and 32 patients ≥80 years. Patients ≥80 years had significantly higher rates of Charlson comorbidity index (9.2 ± 2.4) than younger patients (6.5 ± 2.5; P < 0.001). Arterial hypertension, renal failure, and dementia were significantly more prevalent in octogenarians (P < 0.05). Patients aged ≥80 years had a significantly longer length of hospitalization, while the intensive care unit stay was similar between groups. In-hospital mortality was significantly greater in those ≥80 years (n= 3, 9.4% vs. n= 0, 0.0%; P= 0.029), whereas no differences in 90-day mortality or 30-day readmission were observed. In the second-stage analysis, significant improvements in blood infection parameters and neurologic status were detected in both groups. Of adverse events, pneumonia occurred significantly more frequently in patients aged ≥80 years. Surgical management leads to significant improvements in both laboratory and clinical parameters in older patients. Nevertheless, a personalized medical approach is mandatory in frail patients, especially octogenarians. A clear discussion regarding the potential risk is unambiguously recommended.

Oral Versus Standard Antimicrobial Treatment for Pyogenic Native Vertebral Osteomyelitis: A Single-Center, Retrospective, Propensity Score-Balanced Analysis.

BackgroundInterest in shorter antimicrobial regimens and oral treatment for osteoarticular infections is growing. The aim of this study is to assess whether there is an association between the administration of an entirely oral antibiotic therapy (OT) and the clinical outcome of native vertebral osteomyelitis (NVOs).MethodsWe conducted a single-center, retrospective, observational study on consecutive patients with pyogenic NVOs over a 10-year period (2008–2018). We performed multivariate logistic regression analysis to identify risk factors for clinical failure, both in the whole population and in subgroups. The impact of OT versus standard treatment (intravenous induction followed by oral treatment whenever possible) was assessed in patients with a non-multidrug-resistant microorganism (MDRO) etiology, and the impact of a rifampin-containing regimen was assessed in patients affected by NVOs caused by staphylococci or of unknown etiology.ResultsThe study population included 249 patients, and 33 (13.3%) experienced clinical failure; the OT group consisted of 54 patients (21.7%). Multivariate regression analysis of the whole population selected Charlson comorbidity index (adjusted odds ratio [aOR], 1.291; 95% confidence interval [CI], 1.114–1.497; P = .001) and MDRO etiology (aOR, 3.301; 95% CI, 1.368–7.964; P = .008) as independent factors for clinical failure. Among patients affected by a non-MDRO NVO, OT was not associated with an increased risk of clinical failure (aOR, 0.487; 95% CI, .133–1.782; P = .271), even after adjustment for the propensity score of receiving OT. In the subgroup of patients with staphylococcal or unknown etiology, NVO rifampin was independently associated with favorable outcome (aOR, 0.315; 95% CI, .105–.949; P = .040).ConclusionsAn entirely oral, highly bioavailable treatment, including rifampin, may be as effective as parenteral treatment in selected patients with NVOs.

Decompression only versus fusion in octogenarians with spinal epidural abscesses: early complications, clinical and radiological outcome with 2-year follow-up

Despite increased life expectancy due to health care quality improvements globally, pyogenic vertebral osteomyelitis (PVO) treatment with a spinal epidural abscess (SEA) remains challenging in patients older than 80 years. We aimed to assess octogenarians for PVO prevalence with SEA and compare after-surgery clinical outcomes of decompression and decompression and instrumentation. A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Over 16 years, 35 patients aged ≥80 years with PVO and SEA were identified. Eighteen patients underwent surgical decompression (“decompression group”), and 17 underwent surgical decompression with instrumentation (“instrumentation group”). Both groups had a CCI >6 (mean±SD, 8.9±2.1 vs. 9.6±2.7, respectively; p=0.065). Instrumentation group patients had a significantly longer hospital stay but no ICU stay. In-hospital and 90-days mortality rates were similar in both groups. The mean follow-up was 26.6±12.4 months. No further surgeries were performed. Infection levels and neurological status were improved in both groups at discharge. At the second-stage analysis, significant improvements in the blood infection parameters and the neurological status were detected in the decompression group. Octogenarians with PVO and SEA have a high adverse events risk after surgical procedures. Surgical decompression might contribute to earlier clinical recovery in older patients. Thus, the surgical approach should be discussed with patients and their relatives and be carefully weighed.

Clinical Characteristics of Patients with Pyogenic Vertebral Osteomyelitis and Concurrent Infections and Their Clinical Outcomes.

Patients with pyogenic vertebral osteomyelitis (PVO) often develop concurrent infections, and a significant number of these patients show rapid deterioration in their medical condition, leading to mortality without PVO-related structural instability or neurological deficits. To improve clinical outcomes, we investigated the clinical presentation and treatment outcomes of patients with PVO and concurrent infections. This study included 695 patients with PVO, of which 175 (25%) had concurrent infections and 520 (75%) did not. The clinical characteristics of the two groups were compared, and multivariable analysis was performed to identify the association between concurrent infections and clinical outcomes. Patients with concurrent infections were older and had more comorbidities than those without. Moreover, there were significant intergroup differences in the anatomical involvement of PVO, and patients with concurrent infections had a higher number of regions involved more frequently than those without concurrent infections (15% vs. 6%). In contrast, patients with concurrent infections showed a lower degree of focal invasiveness, including a lower incidence of posterior abscess (47% vs. 59%; p = 0.008) and fewer neurological impairments according to the American Spinal Injury Association grade (p < 0.001) than those without concurrent infections. The causative organisms also differed significantly between the two groups, and patients with concurrent infections had a greater proportion of Gram-negative infections (31% vs. 16%, respectively) and a smaller proportion of methicillin-resistant S. aureus infections than those without concurrent infections (6% vs. 24%). Consequently, their clinical outcomes were significantly different, and patients with concurrent infections showed lower recurrence and higher mortality rates. We investigated the 1-year recurrence and mortality rates and their 95% confidence intervals according to the types of concurrent infections and their time of diagnosis and found variations in these parameters. Our results, based on a large number of patients, can be practically used as a reasonable reference to warn clinicians of the clinical risks of concurrent infections in patients with PVO and to help predict their clinical outcomes.

Novel minimally invasive management of lumbar osteomyelitis: A case report.

Introduction and importanceVertebral osteomyelitis is a rare disease that might lead to significant clinical problems. Initially, conservative therapy is considered to be sufficient for most patients. However, it is not uncommon that the infectious process may become fulminant and severe complications could arise. Recent studies have shown that percutaneous endoscopic debridement provides a favorable outcome in managing lumbar infections without severe neurological symptoms.Case presentationWe presented a case report of a female, 49 years old, with pyogenic vertebral osteomyelitis of the 4th - 5th lumbar spine without neurologic deficit. X-ray examination showed a resemblance of the lytic lesion over the anterior aspect of the L4. We then planned a minimally invasive endoscopic procedure for the patient. We made the 1st portal to aspirate the abscess product and for the endoscopy instrument to debride the remaining debris material. We also developed the second portal using kyphoplasty needl towards the pedicle to gain access to the vertebral body. The debriding process was achieved by positive irrigation pressure from one portal to another using physiologic NaCl saline and gentamicin solution.Clinical discussionCombined with the access created by the kyphoplasty needle, more thorough irrigation was made possible as the intravertebral body was approachable. Compared to open surgery, this approach can reduce surgical damage. Clinically, patient experienced an almost instant relief of pain.ConclusionPercutaneous endoscopic debridement technique in addition of kyphoplasty needle allows wider area for adequate debridement and better result, while maintaining minimally invasive setting with minimum complications.

Life expectancy is poor in patients with diffuse idiopathic skeletal hyperostosis-related pyogenic vertebral osteomyelitis

Life expectancy is poor in patients with diffuse idiopathic skeletal hyperostosis-related pyogenic vertebral osteomyelitis

Периоперационные факторы риска осложнений и рецидивов при гематогенном остеомиелите позвоночника: анализ моноцентровой когорты

Study design Retrospective analysis of a single-center cohort of patients with pyogenic vertebral osteomyelitis. The purpose of the study was to review risk factors for perioperative complications and recurrences in patients diagnosed with hematogenous pyogenic vertebral osteomyelitis. Material and methods 141 inpatient records of hematogenous pyogenic vertebral osteomyelitis were reviewed at the Regional Clinical Hospital No. 2, Tyumen. Patients who developed complications, neurological deficits and recurrences were assigned to A group (n = 66), and those who did not included in B group (n = 75). Results Perioperative complications, recurrences, risk factors and neurological disorders that could develop with different treatment methods were explored. There was a greater risk of recurrences and a lower rate of neurological complications seen in chronic cases and drug addicts. There was a lower risk of intra- and postoperative complications seen in thoracic spine involvement, a greater risk of neurological deficit with involved cervical spine and a lower risk in the lumbar spine involvement. There was a lower risk of neurological disorders in type A and type B disorders, and a greater risk in type C disorders as categorized by E. Pola. There were no differences in recurrence rates among different types of involvement. HIV did not increase the risk of complications and relapses. Surgical site infection developed in 8.1 % cases of transpedicular fixation and in 6.9 % following ventral interventions. No correlation was observed between the recurrence and complication rate and the surgical methods used. Overall, recovery or stable remission was achieved in 88.6 % of cases after treatment of relapses. Conclusion Recurrences and complications were primarily caused by delayed diagnosis, co-morbidities and neurological deficits. No correlation was observed between the recurrence and complication rate and the surgical methods used. There was a greater risk of recurrences and a lower rate of neurological complications seen in chronic cases and drug addicts. Neurological disorders are common for cervical spine disorders. The risk of complications was dependent on the type of involvement as categorized by E. Pola. There was a lower risk of neurological disorders in type A and B disorders and a statistically greater risk in type C disorders.

Clinical Outcomes in Older Patients Aged over 75 Years Who Underwent Early Surgical Treatment for Pyogenic Vertebral Osteomyelitis.

Older patients with pyogenic vertebral osteomyelitis (PVO) usually have more medical comorbidities compared with younger patients, and present with advanced infections from different causative organisms. To aid surgical decision-making, we compared surgical outcomes of older patients with PVO to those who underwent nonoperative treatment. We identified the risk factors for adverse post-operative outcomes, and analyzed the clinical risks from further spinal instrumentation. This retrospective comparative study included 439 patients aged ≥75 years with PVO. Multivariable analysis was performed to compare treatment outcomes among three groups: 194, 130, and 115 patients in the non-operative, non-instrumented, and instrumented groups, respectively. The risk factors for adverse outcomes after surgical treatment were evaluated using a logistic regression model, and the estimates of the multivariable models were internally validated using bootstrap samples. Recurrence and mortality of these patients were closely associated with neurologic deficits, and increased surgical invasiveness, resulting from additional spinal instrumentation, did not increase the risk of recurrence or mortality. We propose that surgical treatment for these patients should focus on improving neurologic deficits through immediate and sufficient removal of abscesses. Spinal instrumentation can be performed if indicated, within reasonable clinical risk.

Validity of Clinical Assessment Using Clinical Symptoms and C-Reactive Protein for Therapeutic Response in Pyogenic Vertebral Osteomyelitis: Analysis Based on 18F-FDG-PET.

Backgroundand objectives: The clinical assessment of therapeutic response in pyogenic vertebral osteomyelitis (PVO) has been usually performed based on the changes of clinical symptoms and blood inflammatory markers. Recently, 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) has emerged as an alternative independent method. We analyzed the validity of the clinical assessment for detecting residual PVO based on 18F-FDG-PET. Materials and Methods: This study was conducted with 53 patients confirmed as lumbar PVO under retrospective design. All patients underwent clinical assessment using clinical symptoms and C-reactive protein (CRP) for therapeutic response after parenteral antibiotic therapy, which led to the decision of placement in the uncontrolled (group UC) or controlled (group C) group. The validity of clinical assessment was analyzed based on the cut-off values of FDG uptake for detecting residual PVO as references, which are already established in the previous literature. Results: The mean duration of parenteral antibiotic therapy and recurrence rate were 42.19 ± 15.84 (21–89) days and 9.4% (5/53), respectively. 18F-FDG-PETs were performed at 80 rounds of clinical assessment on 37.40 ± 13.15 (21–83) days of parenteral antibiotic therapy and divided: 31 into group UC and 49 into group C, according to the decisions of clinical assessment. Based on the cut-off values of FDG uptake, clinical assessment showed 48.4–58.1% of false positive for residual PVO in group UC. However, 18F-FDG-PET showed 8.2% (4/49) of false negative for residual PVO in group C, which led to recurrences. Conclusions: Clinical assessment using clinical symptoms and CRP for evaluating therapeutic response in PVO is still a useful method in terms of similar recurrence rate compared to 18F-FDG-PET. However, the high rate of false positive for residual PVO can prolong the use of unnecessary antibiotics and overall treatment period.

Comparison of serum procalcitonin and interleukin-6 levels with CRP levels in the follow-up of antimicrobial treatment of patients with pyogenic and granulomatous vertebral osteomyelitis

Background/Aim: Infection of the intervertebral disc and adjacent vertebrae is called vertebral osteomyelitis (VO). This study aims to determine whether procalcitonin (PCT) and interleukin (IL)-6 markers are more valuable than white blood cells (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in the follow-up in patients with VO who were administered antibiotherapy. Methods: All adult patients with a diagnosis of VO were included in this prospective cohort study. The patients were divided into two groups as those with pyogenic and granulomatous VO. Serum WBC, CRP, ESH, PCT and IL-6 levels were measured at baseline, and the 2nd, 4th, 8th and 12th weeks of antibiotherapy. The changes in the laboratory parameters of the patients during follow-up were evaluated. Results: Of the 30 patients included in the study, there were 22 and 8 patients in the PVO and GVO groups, respectively. Baseline IL-6 measurement was above the reference in all patients, CRP was elevated in 96.6%, and PCT was increased in only one patient. Although there was a paradoxical increase in PCT values in the PVO group in the 2nd week compared to the pre-treatment values, a rapid decrease was observed in the 4th and 8th weeks. In the GVO group, the gradual decrease in PCT in parallel with the treatment response was considered to predict clinical improvement. IL-6 values decreased by 43.2% and 50% compared to baseline at the 4th and 8th weeks of treatment, respectively, in the PVO group. In the GVO group, a 50% reduction was detected in the 4th week of treatment compared to baseline. Conclusion: PCT and IL-6 biomarkers are valuable indicators in treatment follow-up. Although not statistically significant, the most stable decrease was observed in IL-6. Using IL-6 for the follow-up of the patients with VO may prevent long-term antibiotherapy.

Clinical and Radiological Features Predicting Intervertebral Autofusion after Successful Antibiotic Therapy in Pyogenic Vertebral Osteomyelitis

Background: Pyogenic vertebral osteomyelitis (PVO) is a bacterial infection involving the intervertebral disc, vertebral body, and paravertebral soft tissues. Damaged intervertebral structure is a major cause of persistent back pain even after successful antibiotic therapy, which can be improved by achieving autofusion or via additional surgical fixation. In this study, we analyzed the clinical and radiological features predicting intervertebral autofusion after successful antibiotic therapy in lumbar PVO. Methods: This study was retrospectively conducted with 32 patients (20 men and 12 women) diagnosed with lumbar PVO that was completely cured with no recurrences after antibiotic therapy. They were divided into two groups with (group A, n = 18) and without (group B, n = 14) intervertebral autofusion at six-month follow-up. Differences in back pain, blood inflammatory markers, and radiological features of PVO on simultaneous 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging (18F-FDG-PET/MRI) of the intervertebral structure between the two groups were analyzed. Results: The mean duration of antibiotic therapy was 41.44 ± 14.21 (21–89) days. Group A showed a statistically higher erythrocyte sedimentation ratio (ESR; 59.28 ± 32.33 vs. 33.93 ± 18.76 mm/h, p = 0.014; normal range of ESR < 25), maximum standardized 18F-FDG uptake (SUVmax; 5.56 ± 1.86 vs. 3.98 ± 1.40, p = 0.013), and sustained extensive edematous changes on T2-weighted fat saturation (T2FS) MRI (p = 0.015) immediately after successful antibiotic therapy. However, no significant differences were observed in back pain, C-reactive protein, or the distribution of 18F-FDG uptake/contrast enhancement on 18F-FDG-PET/MRI (p > 0.05). Conclusions: Higher ESR and SUVmax of the intervertebral structure and sustained extensive edematous change on T2FS MRI immediately after successful antibiotic therapy are related with subsequent intervertebral autofusion, which should be carefully considered when assessing therapeutic response in PVO.