Surgical Treatment Of Spondylodiscitis Research Articles

Surgical treatment of spondylodiscitis in critically ill septic patients

PurposeSurgical procedures in critically ill patients with spondylodiscitis are challenging and there are several controversies. Here, we present our experience with offering surgical intervention early in critically ill septic patients with spondylodiscitis.MethodAfter we introduced a new treatment paradigm offering early but limited surgery, eight patients with spondylodiscitis complicated by severe sepsis and multiple organ failure underwent urgent surgical treatment over a 10-year period. Outcome was assessed according to the Barthel index at 12-month follow-up and at the last available follow-up (mean 89 months).ResultsThere were 7 men and 1 woman, with a mean age of 62 years. The preoperative ASA score was 5 in 2 patients, and 4 in 6 patients. Six of them presented with high-grade paresis, and in all of them, spondylodiscitis with intraspinal and/or paravertebral abscesses was evident in MR imaging studies. All patients underwent early surgery (within 24 h after admission). The median time in intensive care was 21 days. Out of the eight patients, seven survived. One year after surgery, five patients had a good outcome (Barthel index: 100 (1); 80 (3); and 70 (1)). At the last follow-up (mean 89 months), 4 patients had a good functional outcome (Barthel index between 60 and 80).ConclusionEarly surgical treatment in critically ill patients with spondylodiscitis and sepsis may result in rapid control of infection and can provide favorable long-term outcome. A general strategy of performing only limited surgery is a valid option in such patients who have a relatively high risk for surgery.

Commentary: The Role of Instrumentation in the Surgical Treatment of Spondylodiscitis and Spinal Epidural Abscess: A Single-Center Retrospective Cohort Study

Spondylodiscitis is an uncommon infection of the intervertebral disc and vertebra with an incidence between 0.2-2.4/100,000 annually. Severe cases can lead to spinal epidural abscess with compressive neurological syndromes.

Complications, Length of Hospital Stay, and Cost of Care after Surgery for Pyogenic Spondylodiscitis.

Infectious Spondylodiscitis is a heterogeneous disease usually affecting a fragile patient population with multiple comorbidities. Therefore, surgical and medical complications are important considerations before initiating treatment. This retrospective analysis included data of 218 patients who underwent surgical treatment for pyogenic Spondylodiscitis between 2008 and 2016. Groups were divided into length of hospital stay (LOS) (group I ≤21 days and group II>21 days). Analysis included patient age, gender, Charlson comorbidity index, smoking, obesity, osteoporosis, colonization with multidrug-resistant bacteria, preoperative neurologic deficit, pre- and postoperative inflammation markers (CRP and WBC), duration of surgery, number of operated segments, vertebrectomy, and postoperative medical and surgical complications. The case value for each patient expressed in Euro was retrieved from hospital records and included in the analysis. Duration of stay after surgical treatment of Spondylodiscitis was ≤21 days (range: 4-21 days; mean: 16 days) in 41% of patients and >21 days (range: 22-162 days; mean: 41 days) in 59% of the patients. Multivariate analysis showed that both medical complications (odds ratio [OR]: 2.62; 95% confidence interval [CI]: 1.24-5.56; p=0.012) and surgical site infection (OR: 6.04; 95% CI: 2.35-15.51; p<0.001) were independently associated with a long hospital stay. Case values averaged at €21,667±1,579 (minimum: €2,888; maximum: €203,802) and correlated significantly with the length of hospital stay (Pearson's correlation coefficient: 0.681; p<0.05). The occurrence of a postoperative complication increased the cost of care significantly from €17,790 to 24,527 on average (p=0.025). This study provides benchmark data for patients treated surgically for Spondylodiscitis. Surgical site infection and medical complications are the main drivers of prolonged hospital stays and cost of care.

The role of MRI diagnostics of non-specific spondylitis

Non-specific purulent-inflammatory lesions of the spine are rather difficult to diagnose and severe diseases. The demand for the problems of diagnosis and treatment of Non-specific purulent-inflammatory lesions is explained by the increase in the incidence of this pathology, the emergence of new antibiotic-resistant strains of microorganisms, the severity of the disease and poor treatment outcomes. The review considers in detail the following vertebral infections: spondylodiscitis and epiduritis. Based on literature data, the authors thoroughly studied and described the etiology, clinical picture and diagnosis of these diseases. Thoroughly covered in the work are modern methods of diagnosing spondylodiscitis and epiduritis: laboratory, radiation methods: spondylography, computed tomography, magnetic resonance imaging, scintigraphy, positron emission tomography of the spine and biopsy data. Detailed description of modern methods of conservative and surgical treatment. Particular attention is paid to the technique of surgical treatment of spondylodiscitis and epiduritis.

The role of MRI diagnostics of non-specific spondylitis

Non-specific purulent-inflammatory lesions of the spine are rather difficult to diagnose and severe diseases. The demand for the problems of diagnosis and treatment of non-specific purulent-inflammatory lesions is explained by the increase in the incidence of this pathology, the emergence of new antibiotic-resistant strains of microorganisms, the severity of the disease and poor treatment outcomes. The review considers in detail the following vertebral infections: spondylodiscitis and epiduritis. Based on literature data, the authors thoroughly studied and described the etiology, clinical picture and diagnosis of these diseases. Thoroughly covered in the work are modern methods of diagnosing spondylodiscitis and epiduritis: laboratory, radiation methods: spondylography, computed tomography, magnetic resonance imaging, scintigraphy, positron emission tomography of the spine and biopsy data. Detailed description of modern methods of conservative and surgical treatment. Particular attention is paid to the technique of surgical treatment of spondylodiscitis and epiduritis.

The Role of Instrumentation in the Surgical Treatment of Spondylodiscitis and Spinal Epidural Abscess: A Single-Center Retrospective Cohort Study

Despite the high incidence of spinal infections that require an operation, there is no consensus on the most appropriate initial surgical management for these patients regarding decompression with vs without instrumented fusion. In this study, we investigated the differences in clinical outcomes, complication rates, and reoperation rates between patients with spinal epidural abscess who underwent decompression alone vs decompression with instrumented fusion. Records of patients undergoing operative intervention for spondylodiscitis with spinal epidural abscess at the authors' institution between 2011 and 2018 were reviewed. Two cohorts were observed: patients who underwent decompression alone and patients who underwent decompression with instrumented fusion as the initial operation. Patient demographics and primary outcomes were analyzed and compared. Medical records of 74 patients with spinal infection were reviewed, and 47 patients met the inclusion criteria. There were 27 (57.4%) patients who underwent decompression alone and 20 (42.6%) patients who underwent decompression and fusion. There were no significant differences in the comorbidities, level, and/or extent of infectious involvement between the decompression alone cohort and the decompression with fusion cohort. Although no significant differences were seen between groups with regard to complication rates and neurological outcomes, the reoperation rate was significantly higher in the patients who underwent decompression alone (51.9% vs 10%, P = 0.004). Decompression with instrumented fusion delivers neurological outcomes and complication rates similar to those seen with decompression alone in patients with spondylodiscitis. However, there was a significantly higher reoperation rate in the decompression only cohort compared to the decompression and fusion cohort.

Neurosurgical Management and Outcome Parameters in 237 Patients with Spondylodiscitis.

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

Operative Treatment of Adult Pyogenic Spondylodiscitis: A Retrospective Study of 32 Cases

BackgroundSpondylodiscitis is a potentially life-threatening infection that imposes a significant financial burden on healthcare systems. Current reports suggest an increase in the incidence of spondylodiscitis, which could be attributed to the aging population and the growing rates of drug abuse. This study aims to evaluate the safety and effectiveness of surgical treatment of spondylodiscitis.Materials and methodsThirty-two cases diagnosed with spondylodiscitis and treated operatively between 2010 and 2015 were enrolled in this study. Indications for surgery were progressive neurologic involvement, progressive spinal deformity or instability, impending fracture, epidural abscess, and poor response to antibiotics. Patients underwent a single-stage procedure. A combined anterior and posterior approach was used in 28 of the patients. In 20 patients, a titanium mesh cage was used for reconstruction. The mean follow-up was 5.6 years.ResultsThere were 18 males and 14 females. The mean age of the patients was 68.4 years (range 56-78). The cervical spine was affected in two cases (6.3%), the thoracic spine in 12 cases (37.5%), and the lumbar spine in 18 cases (56.3%). The most commonly isolated microorganisms were Staphylococcus aureus and Escherichia coli. There was neither mortality nor severe complications. Fusion was achieved in all the patients. There was complete resolution of the neurologic deficits that were recorded preoperatively. No signs of recurrent or residual infection were recorded until the last follow-up.ConclusionsOur data suggest that early detection and surgical intervention of spondylodiskitis is associated with favorable outcomes.

Adjacent segment infection after surgical treatment of spondylodiscitis

BackgroundThis is the first case series to describe adjacent segment infection (ASI) after surgical treatment of spondylodiscitis (SD).Materials and methodsPatients with SD, spondylitis who were surgically treated between 1994 and 2012 were included. Out of 1187 cases, 23 (1.94 %) returned to our institution (Zentralklinik Bad Berka) with ASI: 10 males, 13 females, with a mean age of 65.1 years and a mean follow-up of 69 months.ResultsASI most commonly involved L3–4 (seven patients), T12–L1 (five) and L2–3 (four). The mean interval between operations of primary infection and ASI was 36.9 months. All cases needed surgical intervention, debridement, reconstruction and fusion with longer instrumentation, with culture and sensitivity-based postoperative antimicrobial therapy. At last follow-up, six patients (26.1 %) were mobilized in a wheelchair with a varying degree of paraplegia (three had pre-existing paralysis). Three patients died within 2 months after the ASI operation (13 %). Excellent outcomes were achieved in five patients, and good in eight.ConclusionsAdjacent segment infection after surgical treatment of spondylodiscitis is a rare complication (1.94 %). It is associated with multimorbidity and shows a high mortality rate and a high neurological affection rate. Possible explanations are: haematomas of repeated micro-fractures around screw loosening, haematogenous spread, direct inoculation or a combination of these factors. ASI may also lead to proximal junctional kyphosis, as found in this series. We suggest early surgical intervention with anterior debridement, reconstruction and fusion with posterior instrumentation, followed by antimicrobial therapy for 12 weeks.Level of evidenceLevel IV retrospective uncontrolled case series.

Use of permanently placed metal expandable cages for vertebral body reconstruction in the surgical treatment of spondylodiscitis.

This is a retrospective study of 15 patients treated for spondylodiscitis with implanted metal cages. The purpose of this study is to investigate the outcomes of patients treated with permanently placed metal hardware in vertebral body reconstruction for spondylodiscitis. The use of metal implants in the face of infection has classically been discouraged in orthopedic literature because of the ability of bacteria to form biofilms on metal surfaces. Traditional treatment of spondylodiscitis has been aggressive debridement followed by reconstruction with bone grafts. Expandable metallic cages made reconstruction of these defects significantly easier. However, concern exists that metallic implants affect the resolution of infection. A search of the authors' patient database from 2005 to 2009 revealed 21 patients with spondylodiscitis treated with anterior debridement and reconstruction with an expandable metallic cage. Fourteen patients (15 cases) had sufficient documented clinical follow-up and were available for review. Resolution of infection was determined by evaluating symptoms, laboratory data, and final radiographic result. Of the 15 cases, all had clinical resolution of infection with an average follow-up time of 25 months. An average loss of 1.9° of correction was observed when comparing final follow-up radiographs with initial postoperative radiographs. Radiograph review revealed no extensive osteolysis around the hardware or progressive collapse. These results suggest that the use of expandable metal cages maintains alignment while not perpetuating infection. The spine appears to provide a unique environment that permits the use of metal implants in the setting of infection.

A retrospective study of 113 consecutive cases of surgically treated spondylodiscitis patients. A single-center experience

Recommendations for the operative treatment of spondylodiscitis are still a controversial issue. A retrospective review identified 113 consecutive patients who underwent surgical debridement and instrumentation for spondylodiscitis between 2006 and 2010 at our department. The mean age at presentation was 65 years; 78 patients were male (69 %). Distribution of the inflammation was lumbar in 68 (60 %), thoracic in 19 (17 %) and cervical in 20 (18 %) cases. Six patients (5 %) had two concomitant non-contiguous spondylodiscitis foci in different segments of the spine. Epidural abscess was found in 33 patients (29 %). One hundred four patients (92 %) had pain. Neurological deficit was found in 40 patients (35 %). In the thoracic and lumbar cases, dorsal instrumentation alone was considered sufficient in 26 cases; additional interbody fusion from the posterior was performed in 44 cases. A 360° instrumentation was performed in 22 cases. In the cervical cases, only ventral spondylodesis and plating were performed in eight cases, only dorsal instrumentation in five and 360° instrumentation in seven. Postoperative intravenous antibiotics were administered for 14.4 ± 9.3 (mean ± SD) days followed by 3.2 ± 0.8 (mean ± SD) months of oral antibiosis. Complete healing of the inflammation was achieved in 111 (98 %) cases. Two patients died because of septic shock, both with fulminant endocarditis. Pain resolved in all cases. Neurological deficits were completely resolved in 20 patients, and 14 patients had a partial recovery. The results of our retrospective study show that surgical treatment of spondylodiscitis with a staged surgical approach (if needed) and a short 1-2-week period of intravenous antibiotics followed by 3 months of oral antibiotics is appropriate for most patients in whom conservative treatment has failed or is not advisable. Furthermore, surgical treatment of newly diagnosed spondylodiscitis might be recommended as an initial treatment option in many cases. Thereby the choice of fusion material (autologous bone, titanium, PEEK) seems less important.

Herausforderungen und Besonderheiten der Spondylodiszitiden der Halswirbelsäule

The human cervical spine is a unique structure that differs dramatically from the thoracic and lumbar spine. The main differences concern the topographic anatomy of the spinal cord, anatomy and physiology of the occipito-atlanto-axial joint complex, the close course of the vertebral artery to the cervical spine and the very close relationship of the esophagus, vessels, peripheral and cranial nerves to the spine. To avoid serious complications during surgical treatment of spondylodiscitis within the cervical spine, these aspects must be kept in mind. They will be explained in detail in this article.

Operační léčba spondylodiscitidy

Operační léčba spondylodiscitidy

Surgical treatment of spondylodiscitis in the cervical spine: a minimum 2-year follow-up

Cervical spine spondylodiscitis is a rare, but serious manifestation of spinal infection. We present a retrospective study of 20 consecutive patients between 01/1994 and 12/1999 treated because of cervical spondylodiscitis. Mean age at the time of treatment was 59.7 (range 34-81) years, nine of them female. In all cases, diagnosis had been established with a delay. All patients in this series underwent surgery such as radical debridement, decompression if necessary, autologous bone grafting and instrumentation. Surgery was indicated if a neurological deficit, symptoms of sepsis, epidural abscess formation with consecutive stenosis, instability or severe deformity were present. Postoperative antibiotic therapy was carried out for 8-12 weeks. Follow-up examinations were performed a mean of 37 (range 24-63) months after surgery. Healing of the inflammation was confirmed in all cases by laboratory, clinical and radiological parameters. Spondylodesis was controlled radiologically and could be achieved in all cases. One case showed a 15 degrees kyphotic angle in the proximal adjacent segment. Spontaneous bony bridging of the proximal adjacent segment was observed in one patient. In the other cases the adjacent segments radiologically showed neither fusion nor infection related changes. Preoperative neurological deficits improved in all cases. Residual neurological deficits persisted in three of eight cases. The results indicate that spondylodiscitis in cervical spine should be treated early and aggressive to avoid local and systemic complications.

Spondylodiszitis - ventrale oder ventrodorsale Spondylodese?

Aim: Surgical treatment of spondylodiscitis requires removal of the infected vertebral bodies and discs, defect filling and re-stabilization of the spinal column, usually performed by internal fixation. The present study investigates, if stabilisation by the use of an (external) spinal orthosis leads to a decrease in the rate of bony fusion or an increase in loss of reposition. Method: A retrospective analysis of 29 patients who underwent operative therapy of spondylodiscitis. After radical debridement and bone grafting, stabilisation was performed by use of an external orthosis for 3 months (group 1, n=20). Alternatively, an additional posterior instrumentation (internal fixation) was performed in 9 patients (group 2). Results: After intraoperative correction of the kyphosis of 10° for both groups, a loss of correction of 6.2° at follow up could be observed (group 1: 5.1 ± 6.2°; group 2: 8.0±6.1°). The rate of bony fusion for both groups was 96.5% (group 1: 95%, group 2: 100%). There were no significant differences between the groups. Conclusion: Our results show that debridement of the infected area and bone grafting using a ventral approach followed by the temporary use of a spinal orthosis results in sufficient bony fusion without major loss of reposition.

Surgical treatment of spondylodiscitis.

Spondylodiscitis is a rare bacterial infection of the vertebra and intervertebral discs with an inflammatory, destructive course. To gain further information about the management and clinical course of spondylodiscitis, we retrospectively reviewed 32 patients in 2002 who had surgical interventions between 1992 and 2001. The mean age of patients was 61 years (29-78 years). The mean hospital stay was 47 days (+/- 5.6 days; 3-121 days), including 28 days (+/- 8.1 days; 2-112 days) in the ICU. In-hospital mortality was 6%. The cervical spine was affected in 20% of patients (6/32), the thoracic spine in 25% (8/32), and the lumbosacral spine in 55% (18/32). Abscesses occurred in 63% of patients (20/32) and destruction of the vertebral body in 71% (23/32). Neurological deficits were present in 17 patients, which improved by surgical intervention in 82% of those affected. Thirty-one patients underwent ventral resection of the focus, spondylodesis with a bone graft or titanium cage, and ventral stabilization with a plate. In 19% of patients (6/32), additional dorsal bridging instrumentation was performed. Complete healing was obtained in 94% (30/32) patients. At follow-up, 50% of patients (16/32) had no complaints. Spondylodiscitis requires immediate debridement of the focus, with decompression and stabilization through a ventral approach, when conservative management fails. Otherwise, severe complications occur, such as sepsis, vertebral body destruction, abscess, or neurological deficits.