Search

Background and Research Question: In pyogenic spondylodiscitis, infections with coagulase-negative staphylococci must be given increasing importance. Empirical antibiosis is particularly necessary in patients with severe or progressive neurological deficits or hemodynamic instability, as well as in the case of culture-negative spondylodiscitis. It is unclear whether uniform empirical antibiosis standards adapted to the resistance profiles exist in Germany., Study Design and Methods: A survey on the empirical antibiotic therapy for pyogenic spondylodiscitis was conducted at German university and Berufsgenossenschaft clinics, each in the departments of orthopedics and trauma surgery. The survey results were applied to the resistance profiles of pathogens in 45 spondylodiscitis patients treated in our department between 2013 and 2020. Thus, the potential susceptibility and resistance rates were calculated for the indicated antibiotic therapies., Results: Of the 71 clinics queried, a total of 44 (62.0%) responded. Sixteen different antibiotic therapies were reported as standard regimes. Among these, 14 different combination therapies were reported. The most commonly reported empirical antibiotics, namely amoxicillin/clavulanic acid or ampicillin/sulbactam (29.5%) and cephalosporins (18.2%) showed high potential resistance rates of 20.0% and 35.6%, respectively, in relation to the previously published resistance profile. The highest potential susceptibility rates were achieved with a combination of vancomycin + ampicillin/sulbactam (91.1% sensitive pathogens), vancomycin + piperacillin/tazobactam (91.1% sensitive pathogens), and ampicillin/sulbactam + teicoplanin (95.6% sensitive pathogens). One out of these combinations was reported as standard regime by three clinics (6.8%)., Conclusion: The nationwide survey of empiric antibiotic treatment for pyogenic spondylodiscitis revealed a large heterogeneity in the standard of care. A combination of a broad-spectrum-β-lactam antibiotic with an additional glycopeptide antibiotic may be justified., (© 2022. The Author(s).)

Background: Pyogenic spondylodiscitis is a rare disease that is being diagnosed with increasing frequency in recent years. It is associated with a high morbidity and mortality., Diagnosis: Often, because of its nonspecific symptoms, pyogenic spondylodiscitis is diagnose with some delay. In addition to pathogen detection, MRI is the gold standard to diagnose pyogenic spondylodiscitis. Also, x-ray imaging and CT can be carried out for surgical planning and for subsequent follow-up imaging. If blood or tissue cultures are negative, open surgical biopsies should be preferred over CT-guided biopsies., Therapy: The therapy can be conservative, such as immobilization, as well as antibiotics and analgesics, or surgical. If, for example, neurological deficits, spinale instabilities or deformities, septic disease progression or extensive abscess formations are present, surgical therapy is indicated. The surgical treatment strategies depend on the severity of the disease., Outlook: The prognosis is dependent on a rapid diagnosis and a swift start to therapy. There is no clear evidence with regard to treatment options (conservative vs. surgical therapy).

The choice of implant in an infection of the spine depends on what type of infection it is: discitis, spondylodiscitis, early infection after spinal surgery, or a late infection. The appropriate treatment strategies vary. In spondylodiscitis, a titanium implant may be necessary. In implant-associated early infections, surgical sanitization is often sufficient without changing the implant. In late infections, implant exchange is necessary because of biofilm.

Background: Chronic lumbar pain syndromes without neurological deficits are generated by a multitude of causes. Functional, morphological and psychosocial factors are discussed. In many cases a diseased intervertebral disc is found on radiological examination but the clinical relevance of these findings is not clear. For this study it was postulated that a diseased disc results in a local inflammatory reaction therefore causing pain and impairing treatability of patients. An epidural injection of steroids can reduce inflammation and therefore improve treatability and ultimately treatment outcome., Methods: A double blind randomized prospective trial was carried out. Patients treated in hospital for a chronic lumbar pain syndrome without neurological deficits within a multimodal treatment program were screened for indications for an epidural steroid injection (e.g. diseased lumbar disc and intention to treat). Patients eligible for the study were randomized into two groups. The treatment group received an epidural injection of 80 mg triamcinolone and 8 ml bupivacaine 0.25 %. The control group received only an epidural injection of 8 ml bupivacaine 0.25 %., Results: In both groups pain intensity and treatability showed a statistically significant improvement after the epidural injection. The differences between the control and treatment groups were small and not clinically relevant. A small subgroup might profit from the steroid injection. In addition the treatability was dependent on psychometric values and the long-term outcome from a reduction of muscular skeletal dysfunctions., Discussion: After the epidural injection the decrease in pain and increase in treatability was statistically significant. The mechanism of the improvement is not clear and should be examined further. The epidural injection of a steroid in this subgroup of patients did not lead to a clinical improvement in the outcome.

In most cases spondylodiscitis is due to a monomicrobial infection caused by hematogenous dissemination of Staphylococcus aureus. There are, however, many other possible pathogens causing spondylodiscitis and the pathogen responsible can only be identified in approximately 50% of cases. This leads to delayed diagnosis and therapy and an increased morbidity and mortality rate. Failures in planning and performing material recovery are often the reason. As pathogen-specific antimicrobial treatment according to the results of susceptibility testing is the main component of interdisciplinary therapy, all available methods for identification of the pathogen, such as blood cultures, intraoperative and computed tomography (CT) guided biopsies of inflammatory fluids and tissues as well as molecular biological methods should be performed to optimize antimicrobial therapy.

History and Clinical Findings: Three patients with different forms of vertebral osteomyelitis are presented, two with hematogenous infections caused by Streptococcus pneumoniae and Staphylococcus aureus and one with postsurgical infection after excision of a vertebral disc caused by coagulase-negative staphylococci. None of the patients was initially febrile, but all had localized back pain and a restricted range of movement of the vertebral column. EXAMINATIONS, DIAGNOSIS: In all three patients the MRI of the affected vertebral column was consistent with vertebral osteomyelitis. Microbiological diagnosis was made by bone biopsy in all patients and by blood cultures in two of them., Treatment and Course: Antibiotics were administered for 4-6 weeks. At follow-up two patients were without symptoms, but the third patient had persistent back pain without radiological signs of vertebral osteomyelitis., Conclusion: In patients with localized back pain vertebral osteomyelitis should be included in the differential diagnosis, even if there is no fever and no increase in white cell count, the erythrocyte sedimentation rate or C-reactive protein level and radiography is normal. Specific bacterial diagnosis should be made by multiple bone biopsy or blood cultures, before starting appropriate antibiotics.

With the increasing occurrence of predisposing factors, invasive candidiasis is being diagnosed more frequently. Based on a review of only a few previous reported cases, we describe and discuss the unusual case of candidal cervical spondylodiscitis in a 36 year old man who had sustained a polytrauma, complicated through a Candida albicans pneumonia. The main symptom was disabling neck pain. Clinical, laboratory and radiological findings were unspecific. The definitive diagnosis was determined by MRI imaging and biopsy. The early diagnosis and surgical treatment with a sufficient debridement and stabilisation of the affected segment combined with a prolonged antifungal therapy lead to good results.

Peridural anaesthesia is used to avoid operative, postoperative and chronic pain, especially in surgery, gynecology and urology. Complications have rarely been described but can entail serious local and systemic sequelae. Three cases with spondylitis and spondylodiscitis after peridural anaesthesia are presented. The failure to recognize the peridural catheter as the cause of vertebral pain led to therapeutic delay in two cases. The result of antimicrobial therapy and in two cases radical surgical treatment was complete recovery. The occurrence of spondylodiscitis after the use of peridural catheters is often a late manifestation of disseminated pathogens. The insidious progression of infection and non-specificity of clinical symptoms may lead to diagnostic delay. Awareness of the possibility of even delayed complications after the use of peridural anaesthesia is important.

Background and Aim of the Study: For many years the treatment of spondylitis and spondylodiscitis has been discussed controversially. The aim of this study is to report on objective and subjective mid-term results of therapy of spondylitis and to present a differentiated concept of treatment., Methods: Between 1988 and 1996, 58 patients were treated with spondylitis or spondylodiscitis. Nine of these patients had to be operated. A biopsy was taken in all of the cases. According to the antibiogram obtained by the biopsy, antibiotics were applied intravenously. The patients were immobilized by a plaster bed for at least 6 weeks and were then treated by a spinal orthosis for another 3 months. Patients were re-examined clinically and radiographically and by a questionnaire (including Roland-Morris score), after 8 years on average., Results: Patients were diagnosed correctly 4 months after the begin of the disease. Spondylitis was predominantly localized in the lumbar spine. A positive bacteriological culture was derived from one third of the biopsies; none of them was a specific culture. C-reactive protein was revealed as appropriate for diagnosis and follow-up of spondylitis. In 84% of the patients a total or partial bony fusion was demonstrated radiographically. Questionnaire assessment revealed a significant decrease of the Roland-Morris score (17.8-7.4) and a significant relief of pain (8.9-2.5)., Conclusions: We recommend surgical treatment on patients with major vertebral body destruction, epidural abscess and progressive neurological impairment. These indications for operation can be prevented by a rapid diagnosis, so that spondylitis can be successfully treated by consequent immobilization in a plaster bed and appropriate antibiotics.

Spondylodiscitis is a frequently unrecognized disease in childhood because of unspecific symptoms and late arising or radiological signs. The heterogeneous symptoms, the value of diagnostic procedures and the outcome of 8 patients suffering from spondylodiscitis in the time period of 1989 to 1995 are demonstrated. Guiding symptoms were back pain and refusal to walk or sit. Furthermore, abdominal pain and psoas abscess were the only symptoms in two cases. The pathogenomonical narrowing of the disc space arose in X-ray films earliest 3 weeks after onset of symptoms. The MRI was the best method for early diagnosis and detection of complications. In contrast to persistent radiological changes the clinical outcome was good in most of the patients.

All cases of spondylodiscitis diagnosed in our hospital between January 93 and April 96 have been analysed retrospectively. With regard to potentially severe complications, spondylodiscitis is an important differential diagnosis of back pain. In our results 50% of the patients had a positive bacterial culture either from blood or tissue. No complication has been observed. The most relevant diagnostic procedures are: determination of CRP, magnetic resonance imaging and eventually computed tomography in combination with biopsy and blood cultures. Magnetic resonance imaging is a very sensitive method for early stage osteomyelitis. Antimicrobial therapy should be based on the result of culture and sensitivity tests. An antibiotic with good penetration into bone is preferred.

This study demonstrates that infection of the retro- and intradiscal space is probable, when the temperature rises above over 37 degrees and CRP exceeds 2.0 mcg/ml 5 days postoperatively. MRI of 4 patients confirmed a retrodiscal infection that was indicated by a hyperintense band shaped structure in PS-sequences and which was space occupying with respect to the dural sac. Discitis was demonstrated by intradiscal hyperintensity in STIR images and by enhancement in T1 weighted images following the application of Gadolinium DTPHA. Diagnosis is simplified by comparison of pre- and postoperative MR-examination. Infection can be cured by treatment with antibiotics (Tobramycin and Clindamycin) bedrest and plaster cast.

Long-term outcome and therapy are reported in 29 patients with vertebral osteomyelitis. Antibiotics were administered for a mean period of 21 (6-102) weeks. In 13 patients surgery was additionally necessary. After a mean follow-up of 53 (10-136) months only one relapse had occurred. Radiographs and erythrocyte sedimentation rate were the best indicators of successful treatment.

This study reported on the anamnesis, clinical and instrumental findings as well as therapy in a girl with discitis. The described diagnostic problems and course are characteristic of this frequently unrecognized disease, the cause of which has not yet been fully clarified. Diagnostic and therapeutic procedures suggested in the literature were critically evaluated.