Spondylodiscitis Research Articles

Clinical suspicion of spondylodiscitis with equivocal MRI findings: does diffusion-weighted imaging prove helpful here?

Despite the high sensitivity of magnetic resonance imaging (MRI), early detection of spondylodiscitis (SpD) remains challenging due to its low specificity. To assess the diagnostic value of diffusion-weighted imaging (DWI) in suspected cases of SpD with ambiguous early MRI findings in the differentiation of degenerative disorders (DD). In this prospective study, 52 patients suspected of having SpD underwent a whole-spine 3-T MRI scan comprising sagittal DWI. Of 58 conspicuous, T2-weighted, signal increased discs, 39 were successfully evaluated using DWI. Apparent diffusion coefficient (ADC) values and ADC maps were blindly analyzed using the region of interest of the conspicuous disc and a normal adjacent reference disc. Intraindividual ratios (conspicuous disc: reference disc) were calculated. All conspicuous discs showed increased absolute ADC values, which did not differ significantly between SpD (n = 22) and DD (n = 17). However, ADC ratio was significantly higher in SpD vs. DD (P < 0.05). In receiver operating characteristic curve analysis, an ADC ratio threshold of 1.6 resulted in 45% sensitivity and 88% specificity (area under the curve = 0.69) for SpD diagnosis. The absolute ADC value does not provide a reliable diagnosis of SpD. Increased diffusivity can be an indication of infection but should always be discussed in the context of existing disc degeneration.

Application of oblique lumbar interbody fusion for lumbar intervertebral pyogenic infection

Objective To investigate the safety, key techniques and clinical efficacy of OLIF (oblique lumbar interbody fusion) corridor combined with lumbar intervertebral debridement, fusion with two interbody and internal fixation for the treatment of single-level lumbar pyogenic spondylodiscitis. Methods From February 2016 to March 2017, data of 12 patients with single-level lumbar intervertebral pyogenic infection diagnosed in our hospital who had undergone oblique lumbar interbody fusion with two interbody and posterior pedicle screw fixation via Wiltse approach were retrospectively analyzed. Among them, there were 10 males and 2 females, aged from 49 to 79 years, with an average age of 65.4±9.5 years. The white blood cells (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded and analyzed before operation and at the last follow-up. Lumbar pain was assessed by visual analogue acale (VAS), Oswestry disability index (ODI), and clinical efficacy was assessed by the MOS 36-item short-form health survey (SF-36) and Kirkaldy-Willis criteria. The hospitalization time, operation time, intraoperative blood loss, pathological reports, etiological results and complications were recorded. Disc height (DH), segmental angle (SA) and Lumbar Lordosis (LL) were measured before operation and at the last follow-up. The fusion time was recorded. Paired t-test and ANOVA was used for data analysis. Results All patients underwent surgery successfully, including 6 cases using two titanium meshes and 6 cases using two autologous tricortical iliac bones. Pathogenic culture was positive in 10 cases, with a positive rate of 83.3%, including 4 cases of streptococcus, 4 cases of Staphylococcus aureus, 1 case of Escherichia coli, and 1 case of Klebsiella pneumoniae. All patients were followed up for 16.1±5.1 months. At the last follow-up, WBC ([6.25±2.02] ×109/L) was lower than that before operation ([4.89±1.28] ×109/L), CRP (preoperation 58.73±52.56 mg/L vs postoperation 8.48±8.79 mg/L) and ESR (preoperation 51.88±19.04 mm/1 h vs postoperation 9.25±5.50 mm/1 h) were significantly lower (P< 0.01). The VAS score was preoperation 6.67±1.63 and postoperation 1.50±0.55, ODI score was preoperation 72.57%±3.41% and postoperation 18.00%±2.31%, and both were significantly lower postoperatively (P < 0.01). SF-36 score (preoperation 56.33±4.93 vs postoperation 73.73±5.86) was significantly higher (P< 0.01) respectively. The postoperative height of intervertebral space ([11.68±2.64] mm) was significantly higher than that before operation ([5.18±1.58] mm). The disc height at the last follow-up was (11.22±2.25) mm, and the loss rate was 1.89% compared with that of the immediate postoperatively; The postoperative lumbar lordosis angle (32.89°±14.52°) was significantly increased compared with that of the preoperative (24.16°±13.49°), and maintained well at the last follow-up (32.27°± 14.21°); The postoperative segmental angle (10.8°±8.51°) was significantly increased compared with that of the preoperative (5.81°±7.44°), and maintained well at the last follow-up (9.94°±7.87°). The fusion time ranged from 6 to 16 months, with an average of 9.2±3.5 months. The clinical efficacy was excellent in 10 cases (83.3%) and good in 2 cases (16.7%). The excellent and good rate was 100%. One case of pulmonary infection and pulmonary embolism occurred 2 days after operation, and recovered after use of antibiotics and anticoagulation treatment in ICU; one case of intramuscular venous thrombosis was found 1 day after operation, and recovered after anticoagulation treatment; no loosening of internal fixation was found, and no complications related to OLIF corridor occurred. Conclusion The treatment of single-level lumbar intervertebral pyogenic infection with OLIF corridor combined with lumbar intervertebral debridement, fusion with two interbody and internal fixation has the advantages of less blood loss, shorter operation time, more direct clearance of intervertebral space and left paravertebral focus, no disturbance of intraspinal canal and posterior structure, higher positive rate of etiology detection, shorter bedrest time and better restore of disc height and lumbar lordosis after operation. What’s more, the fusion rate is high and the clinical efficacy is satisfactory. Key words: Lumbar vertebrae; Infection; Spinal fusion

A retrospective study of Spondylodiscitis with clinical, imaging and therapeutic correlations

Introduction: Diagnosing Spondylodiscitis (SD) can be challenging in clinical practice with highly variable outcomes. The aim of this study is to retrospectively analyze the clinical, laboratory, imaging findings of patients with SD treated at our hospital between January 2017 and December 2018. We also evaluated the SD evolution during a short follow-up at 4 and 6 weeks. Methods: The epidemiological, clinical, microbiological, laboratory findings (White Blood Count (WBC), C-Reactive Protein (CRP) and Erythrocyte Sedimentation rate (ESR)), Imaging (CT/MRI) and treatment data of 38 patients with SD were studied retrospectively. The laboratory findings (CRP, ESR) and the CT/MRI examinations during the follow-ups at 4 and 6 weeks were evaluated. Based on imaging (CT/MRI) we divided SD into the following 5 types based on morphological features observed: spondylitis or discitis (ST/DS), SD, SD with paravertebral abscesses (SD-PA), SD with epidural abscess (SD-EP) and SD with paravertebral and epidural abscesses (SD-PEA). Results: The most common complaint was pain (95%) and the main comorbidity was septicemia (42%). Staphylococcus aureus was found in 45% of the cases. The WBC was elevated in 32% of the patients. Both the CRP and ESR decreased during the follow-up. SD was found in 31% of the cases, SD-PA in 26% of the cases, ST/DS in 19% of the cases, SD-PEA in 13% of the cases and SD-EP in 11% of the cases. At the follow-up at week 4, SD-PA, SD-EP and SD-PEA had decreased and were found respectively in 21%, 5% and 5% of the cases. In the follow-up at week 6, SD-PA, SD-EP and SD-PEA were found respectively in 10%, 8% and 3% of the patients. Conservative treatment with antibiotic therapy was applied in 63% of the cases. Surgical treatment was given to 21% of the patients and an interventional procedure was done on 16% of the patients. Conclusion: SD diagnosis and management continues to be based on a multidisciplinary approach. Re-imaging in the critical period of 4-6 weeks with the monitoring of systemic inflammatory markers can be a good follow-up strategy.

Comparative outcomes of operative relative to medical management of spondylodiscitis accounting for frailty status at presentation

PurposeInvestigate outcomes in a spondylodiscitis (SD) patient cohort undergoing operative and medical treatment or medical treatment alone, accounting for frailty status at presentation. MethodsPatients >18 years old undergoing treatment for SD were retrospectively analyzed. The diagnosis of SD was made through a combination of clinical findings, MRI/CT findings, and blood/tissue cultures. Those who failed to respond to antibiotics, had deteriorating markers, or developed neurologic compromise were considered operative candidates. Patients were stratified based on operative (Op, operative plus medical management) or conservative (Cons, medical only) treatment. Univariate analyses identified differences in outcome measures across treatment groups. Conditional forward regression equations, controlling for patient age, identified predictors of increased mortality and inferior outcomes. Results116 patients with SD were included. 73 underwent Cons treatment and 43 were Op. Op patients were significantly younger (62.9vs70.7yrs; p < 0.001) and less frail (1.09vs1.85; p < 0.006) than Cons patients, with significantly higher WCC and ESR. Cons pts had higher rates of isolated SD, but Op pts had higher rates of SD with associated SEA, VOM, psoas abscess, and para-vertebral abscess (all p < 0.05). Op pts had significantly lower 30-day mortality than Cons pts (2.3%vs17.8%, p = 0.016), and trended lower 1Y mortality (11.6%vs20.5%, p = 0.310) with similar SD recurrence rates (11.6%vs16.4%, p = 0.592). Patients with an mFI > 3 had significantly higher 30-day mortality (30.4% vs 7.5%, p = 0.003) and trended higher 1-year mortality regardless of intervention. ConclusionsOperative intervention was associated with lower 30-day mortality significantly and 1-year mortality compared to conservative treatment, while an increased mFI was associated with higher short-term mortality.

Spinal tuberculosis: proposed spinal infection multidisciplinary management project (SIMP) flow chart revision.

We propose a revised flow chart of spinal infection multidisciplinary management project (SIMP) aimed to standardize the diagnostic process and management of spinal tuberculosis (TB). We reviewed data from all TB cases with osteoarticular involvement treated at a large tertiary teaching hospital in Bologna, Northern Italy, from January 2013 to December 2017. We cross-linked notified osteoarticular TB cases with SIMP database and we analysed clinical, diagnostic, and treatment data of all cases managed by SIMP. Osteoarticular TB accounted for the 7.8% (n=40) of all TB cases notified between 2013 and 2017 (N=513). Among the identified cases, 52% (n=21/40) had spine involvement: all were enrolled and evaluated by SIMP multidisciplinary group. Females accounted for 57% (12/21) of patients, the median age was 52 years (range 24-82). In the 67% (n=14/21) of cases, the major clinical symptom of spinal TB was back pain reported for a median of 4.5 months (range 1-12 months) before hospital admission. The interferon gamma release assay was positive in 75% (n=16/21) of patients. All patients performed MRI with gadolinium, which indicated spondylodiscitis in 90%. 18F-FDG-PET/CT revealed average maximum standardized uptake value (SUV max) of 12.54 (range 5.3-22) in 17/19 (89.5%). Bacteriological confirmation of TB was obtained in 86% of cases (n=18/21). One-third of patients (7/21) underwent surgery and 95% successfully completed the anti-TB treatment. Our data reveal that a multidisciplinary approach to spine tuberculosis facilitates early and accurate diagnosis and can improve medical and surgical management of this disease.

Diagnostic and interventional management of infective spine diseases.

Spondylodiscitis (SD) is one of the main causes of back pain. Although the low mortality, high morbidity is related to spondilodiscitys, leading spine instability, chronic pain or neurological deficit. Diagnostic imaging plays a primary role in diagnosing spondylodiscitis. However different accuracy is highlighted by different diagnostic tool, depending also on timing of disease which represents a cardinal element for the phenotypic manifestation of the disease, beyond spatial resolution and tissue characterization proper of specific modality imaging. Conventional Radiology (CR), Computed Tomography (CT) and MRI (Magnetic Resonance Imaging) all have proven to be of primary importance in the approach to spondylodiscitis, although magnetic resonance imaging has demonstrated the greatest advantage in identifying the disease from its earliest stages, demonstrating high sensitivity and specificity (92% and 96%, respectively). This review focus on the role of different imaging modality in the approach to the spondylodiscitis, also addressing the role of interventional radiology that is pivotal not only for a diagnosis of certainty through biopsy, but also for a minimally-invasive treatment of paravertebral abscesses spondylodiscitis-related. (www.actabiomedica.it)

Spondylodiscitis: experience of surgical management of complicated cases after failed antibiotic treatment.

Introduction: The term Spondylodiscitis (SD) involves infection of the vertebra (Spondylitis), infection of the intervertebral disc (Discitis), or both (Spondylodiscitis). SD represents a diagnostic and therapeutic challenge to any spine surgeon. Any delay in its diagnosis or management may cause serious long-term morbidity or even lead to mortality. In this study, we report the experience of our Institution in the management of severe and complicated cases of SD. Methods: Over a period of 1 year, 39 patients with the diagnosis of SD were surgically treated in Assiut University Hospital, Assiut, Egypt. The management processes were tailored according to the clinical condition, radiological and lab studies of each case; and patients were then prospectively followed-up until they were cured (for a minimum of 6 months). The outcomes were analyzed, to be able to give recommendations while aiming to improve the overall outcome of such dangerous health issue. Results: In this series, patients were managed surgically by drainage and debridement of the infection site with/without instrumented fusion. Results included: satisfactory fusion was achieved in 97.3% of patients (confidence interval [CI] = 0.6856–1.3421). Neurological Improvement Rate (NIR) was 71.5% (Statistically significant improvement P-value = 0.014) and reoperation rate was 5% (CI = 0.00621–0.18525). Mortality rate was 7.7% (CI = 0.016–0.209). Several aspects were analyzed in each case. Conclusion: Surgical management of severe and complicated cases of SD allows for effective debridement and rapid cure of inflammation, earlier patient mobilization and significantly shorter duration of antibiotic usage.

Efficacy and safety of minimally invasive axial presacral L5-S1 interbody fusion in the treatment of lumbosacral spine pathology: a retrospective clinical and radiographic analysis.

Background:The surgical treatment of degenerative disc disease L5-S1 is considerably controversial. The purpose of this study was to evaluate the radiographic and clinical results of patients treated with AxiaLif® Technique (AxiaLif®, AMSGroup, Italy) using a minimally invasive pre-sacral approach.Methods:From 2013 to 2018 a total of 52 patients have been treated (12 M, 40 F; mean age 46.3 years). Diagnosis included L5 isthmic spondylolisthesis low-grade dysplasia, primary and secondary degenerative disc disease. 43 patients have been followed for at least 2 years. Fusion assessment was based on plain radiographs and Brantigan fusion criteria at 1, 6, 12 and 24 months after surgery. All patients completed the VAS and ODI at baseline through last follow-up.Results:Clinical results showed good pain resolution. VAS back demonstrated an average reduction over baseline of 50%, 57%, 71%, 77% at 3, 6, 12 and 24 months, respectively (p<0.001). ODI demonstrated an average reduction over baseline of 38%, 51%, 67%, and 72% at the same time points (p<0.001). Complete fusion was demonstrated in 65% of cases, 30% partial fusion and 5% in the absence of bony bridges visible radiographically. We had two major complications, as 1 retroperitoneal hematoma and 1 spondylodiscitis, and one minor complication, as a superficial infection of the surgical wound.Conclusions:The surgical treatment of degenerative disc disease at L5-S1 with minimally invasive technique Axialif showed good radiographic and clinical outcomes with an acceptable rate of complications. Moreover, shorter hospitalization and faster functional recovery are adding factors to choice this technique. (www.actabiomedica.it)

Minimally invasive spinal fusion and decompression for thoracolumbar spondylodiscitis.

Objective:The objective was to study the results of the treatment of thoracolumbar spondylodiscitis (SD) through minimally invasive fusion and decompression technique.Materials and Methods:All the patients were evaluated clinically and radiologically (X-ray, magnetic resonance imaging, and computed tomography scan) along with necessary laboratory investigations. They underwent the minimally invasive spinal (MIS) decompression and fusion procedure using tubular retractor system and percutaneous transpedicular fixation done under fluoroscopy guidance. They were assessed using pre- and postoperative Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Kirkaldy-Willis functional outcome criteria. Postoperative radiological assessment of fusion was done. Operating time and fluoroscopy duration were also studied.Results:There were a total of 12 patients, with an equal sex ratio of 1:1 with 8 and 4 patients having the involvement of the lumbar and dorsal spine, respectively. The fixation was done in the involved vertebrae in 8 patients and adjacent normal vertebrae in 4 patients. There was an improvement in VAS score from 7.8 to 2.1 and ODI from 64.3 to 16.4. 4 patients had excellent, 7 had good, and 1 had fair outcome in Kirkaldy-Willis functional outcome criteria. There was Grade 2 and 3 fusion in 4 cases each, and 2 patients had Grade 4 fusion. The laboratory studies were found positive for tuberculosis in 3 cases with 7 having necrotizing granulomatous inflammation, and 2 patients had negative results.Conclusion:The MIS procedure is a safe and effective method of the management of SD in the thoracolumbar spine.

Spondylodiscitis after minimally invasive recto- and colpo-sacropexy: Report of a case and systematic review of the literature.

Background:Rectopexy and colpopexy are established surgical techniques to treat pelvic organ prolapse. Spondylodiscitis (SD) after rectopexy and colpopexy represents a rare infectious complication with severe consequences. We presented a case of SD after rectopexy and performed a systematic review.Methods:A systematic literature search was performed to identify case reports or case series reporting on SD after rectopexy or colpopexy. The main outcomes measures were time from initial surgery to SD, presenting symptoms, occurrence of mesh erosion or fistula formation and type of treatment.Results:Forty-one females with a median age of 59 (54–66) years were diagnosed with SD after a median of 76 (30–165) days after initial surgery. Most common presenting symptoms were back pain (n = 35), fever (n = 20), pain radiation in the legs (n = 9) and vaginal discharge (n = 6). A mesh erosion (n = 8) or fistula formation (n = 7) was detected in a minority of cases. The treatment of SD consisted of conservative treatment with antibiotics alone in 29%, whereas 66% of the patients had to undergo additional surgical treatment. If a revision surgery was necessary, more than one intervention was performed in 40%. Mesh and tack excision was performed in most cases (n = 21), whereas a neurosurgical intervention was necessary in 10 patients.Conclusion:Although a rare complication, surgeons performing rectopexy and colpopexy must be aware of the potential risk of SD Careful suture or tack placement into the anterior longitudinal ligament at the level of the promontory while avoiding the disc space is of paramount importance. Prompt diagnosis and multidisciplinary management are the cornerstones of a successful treatment.

Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults.

Diagnosis of spondylodiscitis (SD) may be challenging due to the nonspecific clinical and laboratory findings and the need to perform various diagnostic tests including serologic, imaging, and microbiological examinations. Homogeneous management of SD diagnosis through international, multidisciplinary guidance would improve the sensitivity of diagnosis and lead to better patient outcome. An expert specialist team, comprising nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), neuroradiologists appointed by the European Society of Neuroradiology (ESNR), and infectious diseases specialists appointed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), reviewed the literature from January 2006 to December 2015 and proposed 20 consensus statements in answer to clinical questions regarding SD diagnosis. The statements were graded by level of evidence level according to the 2011 Oxford Centre for Evidence-based Medicine criteria and included in this consensus document for the diagnosis of SD in adults. The consensus statements are the result of literature review according to PICO (P:population/patients, I:intervention/indicator, C:comparator/control, O:outcome) criteria. Evidence-based recommendations on the management of adult patients with SD, with particular attention to radiologic and nuclear medicine diagnosis, were proposed after a systematic review of the literature in the areas of nuclear medicine, radiology, infectious diseases, and microbiology. A diagnostic flow chart was developed based on the 20 consensus statements, scored by level of evidence according to the Oxford Centre for Evidence-based Medicine criteria. This consensus document was developed with a final diagnostic flow chart for SD diagnosis as an aid for professionals in many fields, especially nuclear medicine physicians, radiologists, and orthopaedic and infectious diseases specialists.

SPONDYLODISCITIS DIAGNOSTICS IN NOWADAYS: BASIC CT AND MRI SIGNS

For many reasons spondylodiscitis (SDC) is a complicated pathology. It is caused by difficulty in early diagnostics, the need for surgical treatment (including repeated interventions), long term and high cost of antibiotic therapy. Objective. The goal is to identify and describe the main CT and MRI symptoms of SDC, to assess their frequency and specificity. The next aim is to note the peculiarities of the radiologist’s practice with such patients. Materials and methods. We studied the data of 25 patients with proved SDC, and we analyzed CT and MRI symptoms (both common and rare), and the role of contrast enhancement (СE) in both methods and important clinical and laboratory aspects. Results.The infiltration of vertebral bodies and intervertebral discs were the most frequent SDC signs, abscesses also were very common. The most significant type of abscess was epidural which led to the formation of vertebral canal stenosis and to neurological deficit. The important methodological aspects of the MRI study were noted to improve its quality. Conclusion. We recommend performing both CT and MRI, if possible, for all patients with SDC because of the different diagnostic tasks that are important for clinicians.CE significantly increases the MRI informativity.

Infection after spinal surgery and procedures.

Postoperative infections after spinal surgery are a challenging issue, difficult to diagnose and treat, that requires prolonged medical therapy and even surgery. In this paper, we aim to review the current standards in the diagnosis and treatment of post-procedural Spondylodiscitis (SD). We performed a review of the available literature focusing on diagnostic and therapeutic standards of post-procedural SD, both after minimally invasive procedures and open surgery. Spinal infections can occur in less invasive procedures with an incidence ranging from 0.26% to 2.75%. Post-surgical spinal infections range from 2.1% to 8.5% for instrumented surgery, whereas these are less than 1% in open surgery without instrumentation. MRI is currently the most sensitive and specific technique to diagnose postoperative SD. CT guided aspiration culture should be performed in all patients with deep-seated infections with negative blood cultures. Early infections start with wound healing problems within a few weeks from surgery, and the occurrence of fever and an increase in serum markers of inflammation. Late infections often cause chronic pain, implant failure, non-union or wound dehiscence even a long time after surgery. The onset of the infection differentiates the specific treatment. Indeed, in the early postoperative period spinal fusion is not appropriate yet, and the stability of the fusion site only relies on the instrumentation. Therefore, even when suitable, implant removal may lead to undesirable consequences. In chronic infections, on the other hand, implant removal is unlikely to determine instability since the fusion has already been accomplished.

Spondylodiscitis: is really all well defined?

The term spondylodiscitis describes the infection of both the intervertebral disc space and the adjacent vertebrae. Pyogenic Vertebral Osteomyelitis (PVO) is more common in older patients (mean age 59-69 years) with a male preponderance (52-69%). Recent studies reported an alarming increase of incidence over the last 20 years, due to the increase of diagnostic sensibility, the increase of the average lifetime and to the consequent association of chronic disabling pathologies, of immunosuppression, of surgical or invasive procedure. Improvements in radiological diagnosis, surgical techniques, and management of antimicrobial therapy have greatly improved PVO clinical outcome, but morbidity remains significant mostly because of the delay of diagnosis. The non-specific features of this infection can lead to underestimate the patient conditions, ending to a significant delay in diagnosis, reported from 30 to 90 days, and consequently to severe impairments, such as spine deformity and permanent neurological deficit. The duration of medical treatment is not yet established, and further randomized trials are needed to define it.

The role of histology in the diagnosis of spondylodiscitis: correlation with clinical and microbiological findings.

The aim of this study was to determine the diagnostic utility of histological analysis in spinal biopsies for spondylodiscitis (SD). Clinical features, radiology, results of microbiology, histology, and laboratory investigations in 50 suspected SD patients were evaluated. In 29 patients, the final (i.e. treatment-based) diagnosis was pyogenic SD; in seven patients, the final diagnosis was mycobacterial SD. In pyogenic SD, the neutrophil polymorph (NP) infiltrate was scored semi-quantitatively by determining the mean number of NPs per (×400) high-power field (HPF). Of the 29 pyogenic SD patients, 17 had positive microbiology and 21 positive histology (i.e. one or more NPs per HPF on average). All non-SD patients showed less than one NP per HPF. The presence of one or more NPs per HPF had a diagnostic sensitivity of 72.4%, specificity 100%, accuracy 100%, positive predictive value (PPV) 81.0%, and negative predictive value (NPV) 61.9%. Sensitivity, specificity, and accuracy were greater using the criterion of positive histology and/or microbiology than positive histology or microbiology alone. Granulomas were identified histologically in seven mycobacterial SD patients, and positive microbiology was detected in four. The diagnosis of pyogenic SD was more often confirmed by positive histology (one or more NPs per HPF on average) than by microbiology, although diagnostic sensitivity was greater when both histology and microbiology were positive. Cite this article: Bone Joint J 2019;101-B:246-252.

Conservative Treatment of Spondylodiscitis: Possible Therapeutic Solution in Case of Failure of Standard Therapy.

Introduction:Spondylodiscitis (SD) is an uncommon disease but not rare, because it represents around 3–5% of all cases of osteomyelitis. Late diagnosis and/or inadequate treatment often cause irreversible damage to cause neurological deficit. Most require only conservative treatment, sometimes a surgical approach is required.Aim:The purpose of this study is to propose a conservative protocol to treat spondylodiscitis when the standard conservative treatment has failed. This alternative treatment has been for a long time at the Codivilla-Putti Institute.Methods:We performed a prospective cohort study of 192 consecutive patients who underwent paravertebral intramuscular injections of antibiotic associated with standard treatment at our Center from January 2010 to December 2015 with SD. Of this 192 patients we selected 98 who had already undergone standard antibiotic therapy at another hospital without resolution of the disease. All patients have performed our protocol that provides a total of 3 cycles, each of 3 weeks, repeated at approximately 5 weeks apart. For each patient we evaluated Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), White Blood Cells (WBC) indexes, SF36 and VAS Score at the beginning and at the end of the treatment.Results:At a mean follow up of 22 months (range 60-12), clinical healing was achieved in 87 patients (88,9%) of cases with significant reduction in back pain and functional limitation. The VAS Score and the SF36 were better at the end of treatment compared to previous “GOLD STANDARD” treatments in the previous hospitalization in another hospital. In most cases there were slightly reduced in inflammatory indexes.Conclusion:There are no studies in the literature demonstrating the effective efficacy of local infiltrative treatment with antibiotics, associated with standard treatment protocol. We believe that our protocol in treating SD, favors an early functional recovery, and be able to offer more chance of success than the standard treatment.

Infectious spondylodiscitis: A twenty-year experience from a single tertiary referral center

Aim of the workTo study microbiological, clinical and therapeutic aspects of spondylodiscitis (SD) and predisposing risk factors in Tunisian patients. Patients and methodsPatients with SD admitted to Rheumatology Departments, Southern Tunisia, were retrospectively studied. Medical records were reviewed over the last 20-years and investigations included bacterial cultures, magnetic resonance imaging (MRI) or computed-tomography percutaneous disc biopsy (CT-PDB). ResultsThere were 67 SD cases (incidence of 0.17/100,000 inhabitants/year); 38 men and 29 women and mean age was 55 ± 16 years. Advanced age, tuberculosis and brucellar contagion were the predominant risk factors. The duration from onset to diagnosis was 133.6 ± 115 days. Low back pain (LBP) was the most common symptom. Lumbar spine was the most frequent location. Neurologic symptoms (radicular pain, spinal chord compression, neurologic loss) were observed in 31 patients. C-reactive protein was elevated in 54 (52.17 ± 43.97 mg/L). MRI showed abnormalities in 60 patients and CT-PDB was performed in 39. Pathogens were isolated in 43 cases. Mycobacterium tuberculosis (MT) was the most common (55.8%) followed by staphylococcus aureus (18.6%), brucella (16.3%), Escherichia coli (EC) (4.7%) and streptococcus-β in 1 patient; 1 patient had both MT and EC. Medical treatment was prescribed in 91% and surgery performed in 6. 88% of patients improved after 24 months follow-up. ConclusionSpondylodiscitis should be considered for all patients presenting with chronic LBP with systemic symptoms and evidence inflammation. MRI is required to establish a diagnosis and evaluate the spread of infection. CT-PDB is useful to identify the causative micro-organism before antibiotic administration. These findings could to pave the way for constructing national guidelines.

Latent spondylodiscitis following elbow cellulitis: A case report and literature review

Spondylodiscitis is usually caused by hematogenous spread, and recently there have been only a few published reports citing the soft tissue as the hematogenous source. We present an unusual case of pyogenic spondylodiscitis following elbow cellulitis. In addition to white blood cell (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) values, we checked the procalcitonin (PCT) level to confirm if the infection was in acute phase. Although the patient’s fever subsided after administration of antibiotics, the neurologic claudication worsened, and we performed an anterior debridement and interbody fusion combined with posterior instrumentation. The direct lateral retroperitoneal approach, which we adapted, has the advantage of excellent exposure for irrigation, debridement, and reconstruction without requiring blood vessel mobilization or manipulation of the peritoneal contents. After surgery, intravenous antibiotics were administered for 6 weeks, followed by oral antibiotics until the CRP normalized and the ESR was decreasing. The patient made an uneventful recovery, with no significant neurologic sequelae reported at outpatient follow-up evaluations. The purpose of this case report is to inform clinicians of the potentially severe complication of spondylodiscitis following cellulitis and describe a modified approach to surgical treatment.

Analysis of infectious spondylodiscitis: 7-years data.

Objective:Infectious spondylodiscitis (SD) is an infectious disease that is rare and difficult to diagnose due to its non-specific clinical features. In this study, we aimed to describe the clinical and diagnostic features of infectious spondylodiscitis.Methods:All patients who were diagnosed with SD at our hospital during a 7-year period from January 1, 2011 through December 31, 2017 were included in the study. Spondylodiscitis is divided into the following three types: pyogenic, tuberculous, and brucellar. Clinical and laboratory data were collected retrospectively from the medical records of the patients.Results:Of the 118 patients, 66 (55.9%) were female, 81 (68.6%) had pyogenic SD (PSD), 21 (17.8%) had tuberculous SD (TSD), and 16 (13.6%) had brucellar SD (BSD). The mean age was 59.3 ± 14.6 years. Leucocytosis was significantly higher in patients with PSD (p=0.01) than in patients with other types of SD. Thoracic involvement (47.6%) was significantly higher in patients with TSD (p=0.005) than in other patients. Sacral involvement (12.5%) was significantly higher in patients with BSD (p=0.01) than in other patients. Paravertebral abscess formation (42.8%) occurred most frequently in patients with TSD. Microbiologic agents were defined in 50% (18/36) of the surgical specimens and in 12.5% of the fine needle aspiration biopsy (FNAB) specimens. Staphylococcus aureus was the most common microbiological agent in patients with PSD. Spinal surgery was defined as a risk factor for PSD (p = 0.0001). Binary logistic regression analysis revealed that female gender, thoracic involvement and night sweats were the predictive markers for TSD (OR 4.5 [95% CI 1.3-15.3] and OR 5 [95% CI 1.7-14.6]).Conclusion:PSD is the most frequent form of SD. Leucocytosis is most common in patients with PSD. Thoracic involvement and paraspinal abscess were prominent in patients with TSD. Sacral involvement was most common in patients with BSD. Thoracic involvement, female gender and night sweats were the predictive markers for TSD. The microbiological culture positivity rate was higher in surgical specimens compared to FNAB specimens. The need for surgical treatment was most common in patients with TSD.

Een zeldzame verwikkeling van infectieuze endocarditis

In this case-report, a 91-year-old female patient presented with invalidating lumbar back pain and persisting high inflammatory markers, after a fall. Since the back pain was not improving and given the persisting inflammatory results, hemocultures were blindly taken which proved positive for Streptococcus gallolyticus. An MRI scan visualized the destruction of the vertebral bodies L1 and L2 with an inflammation of the soft tissue, which could confirm the diagnosis of spondylodiscitis. In this patient with a systolic murmur but without history of heart disease, endocarditis was diagnosed via echocardiography. Therapy consisted of bed rest, adequate pain relief and intravenously administered penicillin and gentamycin. This treatment had a favorable evolution on the pain and inflammatory markers. In the discussion, a brief review of the recent literature has been given concerning infectious endocarditis and spondylodiscitis.