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Patients with advanced pyogenic spondylodiscitis can present with neurologic deficits. However, the prevalence, severity, and outcome of the neurologic deficits are not well known. A systematic review was performed to improve the knowledge of this commonly encountered clinical scenario. The considerable number of severe neurologic deficits in addition to their poor recovery, even after surgical intervention, demonstrates that the early diagnosis of pyogenic spondylodiscitis is crucial. Prompt surgical intervention is likely associated with a greater chance of improvement of neurologic status than nonsurgical treatment.

ObjectiveTreatment strategies of patients suffering from pyogenic spondylodiscitis are a controverse topic. Percutaneous dorsal instrumentation followed by surgical debridement and fusion of the infectious vertebral disc spaces is a common approach for surgical treatment. Technical advances enable spinal navigation for dorsal and lateral instrumentation. This report investigates combined navigated dorsal and lateral instrumentation in a single surgery and positioning for lumbar spondylodiscitis in a pilot series.MethodsPatients diagnosed with 1- or 2-level discitis were prospectively enrolled. To enable posterior navigated pedicle screw placement and lateral interbody fusion (LLIF) patients were positioned semi-prone in 45-degree fashion. For spinal referencing, a registration array was attached to the pelvic or spinal process. 3D scans were acquired intraoperatively for registration and implant control.Results27 patients suffering from 1- or 2-level spondylodiscitis with a median ASA of 3 (1–4) and a mean BMI of 27.9 ± 4.9 kg/m2 were included. Mean duration of surgery was 146 ± 49 min. Mean blood loss was 367 ± 307 ml. A median of 4 (4–8) pedicle screws were placed for dorsal percutaneous instrumentation with an intraoperative revision rate of 4.0%. LLIF was performed on 31 levels with an intraoperative cage revision rate of 9.7%.ConclusionsNavigated lumbar dorsal and lateral instrumentation in a single operation and positioning is feasible and safe. It enables rapid 360-degree instrumentation in these critically ill patients and potentially reduces overall intraoperative radiation exposure for patient and staff. Compared to purely dorsal approaches it allows for optimal discectomy and fusion while overall incisions and wound size are minimized. Compared to prone LLIF procedures, semi-prone in 45-degree positioning allows for a steep learning curve due to minor changes of familiar anatomy.

Percutaneous intervertebral disc puncture is useful in various situations. The isocenter puncture method enables easy, accurate, and safe punctures under fluoroscopic guidance. Herein, we present a clinical application of this technique that improves upon percutaneous puncture of intervertebral discs.We performed percutaneous punctures of intervertebral discs slightly lateral to the superior articular process using the isocenter puncture method in 19 cases (10 men, 9 women; mean age, 64.5 years; range, 23-87 years). We assessed the technical success rate, procedure time, and complications.We achieved successful punctures in all cases, with a median puncture time of 14.5 min (mean, 18.7 ± 11.3 min; range, 8-49 min). No patients complained of complications that were permanent or required treatment.Improved puncture of intervertebral discs seems to be possible using the isocenter puncture method.

Pyogenic spondylodiscitis (PS) is more common in patients aged over 50 years and it represents only 1-2% of bone infectionsin pediatric age. The incidence has been rising through the combined effect of an increase in the susceptible population (immunosuppressed and ageing population), intravenous drug use, rise in healthcare-associated infection, spinal surgery and improved ascertainment, due to better diagnosis. Of 173 patients, 15 patients with incomplete follow-up, incomplete radiographic data and 7 patients with inconclusive etiological diagnosis were also excluded. The remaining 151 patients formed the basis of the study. Mean duration of symptoms was 6 weeks in NTS and 14 weeks in TS. Back ache is the most common clinical feature seen in all patients (100%). Fever in NTS (71.1%) and deformity in TS (34.3%) were 2nd most common clinical features respectively. Neurological deficits and symptoms (radiculopathy/parasthesias) were present in 30.3% of TS and 21.1% of NTS.

Die eitrige Spondylodiszitis ist eine seltene Erkrankung die in den letzten Jahren immer haufiger diagnostiziert wird. Sie ist mit einer hohen Morbiditat und Mortalitat verbunden. Durch ihre unspezifische Symptomatik wird die eitrige Spondylodiszitis haufig erst mit einiger Verzogerung diagnostiziert. Neben einem Erregernachweis ist die MRT als Goldstandard zielfuhrend. Erganzend kann zur operativen Planung und zu spateren Verlaufskontrollen eine Rontgenuntersuchung und/oder ein CT vorgenommen werden. Bei fehlendem Keimnachweis im Blut oder anderem Gewebe sollte die offene Biopsie der CT-gesteuerten Biopsie vorgezogen werden. Die Therapie kann konservativ mittels Ruhigstellung und adaquater Antibiotika- und Schmerztherapie oder chirurgisch erfolgen. Bei neurologischen Defiziten, Instabilitaten oder Deformitaten der Wirbelsaule ist die chirurgische Therapie indiziert. Die operativen Behandlungsstrategien hangen dabei von der Schwere der Erkrankung ab. Die Prognose ist abhangig von einer schnellen Diagnose und einem zugigen Begin der Therapie. Eine eindeutige Evidenz im Bezug auf die Therapie (konservativ vs. chirurgisch besteht nicht.

STUDY DESIGN Retrospective multicenter case series. OBJECTIVE We sought to evaluate the safety and efficacy of anterior cervical plating in anterior cervical debridement and fusion (ACDF) for patients with cervical pyogenic spondylodiscitis (CPS). SUMMARY OF BACKGROUND DATA Due to concerns about bacterial seeding on the foreign material after instrumentations in pyogenic infections, the safety and efficacy of anterior cervical plating for CPS are still undetermined and controversial. Little information is available about the safety and efficacy of anterior cervical plating to manage CPS. METHODS Twenty-three patients who underwent ACDF with (n = 12) or without (n = 11) plating for CPS were included. The mean age was 62.6 years. Medical records were reviewed and radiological parameters including segmental height, segmental angle, C2-C7 angle, and fusion status were analyzed. The mean follow-up period after surgery was 21.3 months. RESULTS After ACDF with plating, segmental height, segmental angle, and C2-C7 angle were significantly improved compared with preoperative conditions and remained well-maintained at the last follow-up. After ACDF without plating, three radiological parameters were also initially improved compared with preoperative condition, but significantly deteriorated to preoperative levels at the time of the last follow-up. The fusion rate was higher in the ACDF with plating group compared with the ACDF without plating group (90.9% vs. 63.6%; P

Background and Objectives: The incidence of pyogenic spondylodiscitis has been increasing due to the aging of the population. Although surgical treatment is performed for refractory pyogenic spondylodiscitis, surgical invasiveness should be considered. Recent minimally invasive spine stabilization (MISt) using percutaneous pedicle screw (PPS) can be a less invasive approach. The purpose of this study was to evaluate surgical results and clinical outcomes after MISt with PPS for pyogenic spondylodiscitis. Materials and Methods: Clinical data of patients who underwent MISt with PPS for pyogenic spondylitis were analyzed. Results: Twenty-three patients (18 male, 5 female, mean age 67.0 years) were retrospectively enrolled. The mean follow-up period was 15.9 months after surgery. The causative organism was identified in 16 cases (69.6%). A mean number of fixed vertebrae was 4.1, and the estimated blood loss was 145.0 mL. MISt with PPS was successfully performed in 19 of 23 patients (82.6%). Four cases (17.4%) required additional anterior debridement and autologous iliac bone graft placement. CRP levels had become negative at an average of 28.4 days after surgery. There was no major perioperative complication and no screw or rod breakages during follow-up. Conclusions: MISt with PPS would be a less invasive approach for pyogenic spondylodiscitis in elderly or immunocompromised patients.

Background and Objectives: Spinal minimally invasive surgery (MIS) experts at the university hospital worked as a team to develop a new treatment algorithm for pyogenic spondylodiscitis in lumbar and thoracic spines. They modified a flow chart introduced for this condition in a pre-MIS era to incorporate MIS techniques based on their extensive experiences accumulated over the years, both in MIS for degenerative lumbar diseases and in the treatment of spine infections. The MIS procedures incorporated in this algorithm consisted of percutaneous pedicle screw (PPS)–rod fixation and transpsoas lateral lumbar interbody fusion (LLIF). The current study analyzed a series of 34 patients treated with prospective selection of the methods according to this new algorithm. Materials and Methods: The algorithm first divided the patients into those who had escaped complicated disease conditions, such as neurologic impairment, extensive bone destruction, and the need to be mobilized without delay (Group 1) (19), and those with complicated pyogenic spondylodiscitis (Group 2) (15). Group 1 had image-guided needle biopsy followed by conservative treatment alone with antibiotics and a spinal brace (12) (Group 1-A) or a subsequent addition of non-fused PPS–rod fixation (7) (Group 1-B). Group 2 underwent an immediate single-stage MIS with non-fused PPS–rod fixation followed by posterior exposure for decompression and debridement through a small midline incision (12) (Group 2-A) or an additional LLIF procedure after an interval of 3 weeks (3) (Group 2-B). Results: All patients, except four, who either died from causes unrelated to the spondylodiscitis (2) or became lost to follow up (2), were cured of infection with normalized CRP at an average follow up of 606 days (105–1522 days). A solid interbody fusion occurred at the affected vertebrae in 15 patients (50%). Of the patients in Group 2, all but two regained a nearly normal function. Despite concerns about non-fused PPS–rod instrumentation, only seven patients (21%) required implant removal or replacement. Conclusions: Non-fused PPS–rod placements into infection-free vertebrae alone or in combination with posterior debridement through a small incision worked effectively in providing local stabilization without contamination of the metal implant from the infected tissue. MIS LLIF allowed for direct access to the infected focus for bone grafting in cases of extensive vertebral body destruction.

BACKGROUND AND PURPOSE: Differentiation between tuberculous and pyogenic spondylodiscitis is a diagnostic challenge because imaging often does not reliably distinguish the 2 entities and percutaneous biopsies are often culture-negative. The purpose of this study was to determine whether violation of the anterior meningovertebral ligament in the setting of anterior epidural abscess discriminates between these entities. MATERIALS AND METHODS: This was a retrospective cohort study of all patients with acid-fast bacillus testing and anterior epidural abscess diagnosed on spinal MR imaging between May 2014 and September 2019, with a final diagnosis of tuberculous or pyogenic spondylodiscitis. Six cases of tuberculous spondylodiscitis (mean age, 45.5 years; 80% male) and 35 cases of pyogenic spondylodiscitis were evaluated (mean age, 56.6 years; 49% male). Demographic characteristics were recorded. Cases were assessed for anterior meningovertebral ligament destruction on MR imaging, as demonstrated by the shape of the epidural collection. Segmental location of the infection was also assessed. Independent 2-sample t tests and χ(2) tests of independence were performed to evaluate the significance of the difference between the groups. RESULTS: Five of 6 (83.3%) cases of tuberculous epidural abscess had an intact anterior meningovertebral ligament, and 0/35 cases of pyogenic epidural abscess demonstrated an intact ligament (P

Background Pyogenic spondylodiscitis is diagnosed in recent years at higher rates due to the aging population, increased survival of chronic and immune suppressed patients, and the higher rate of invasive procedures leading to bacterial seeding or direct contamination of the disc space. Treatment guidelines encourage bacterial sampling before initiation of antibiotic therapy, and drainage of pus collections. We present our experience with percutaneous CT-guided drain insertion into the disc space itself as a one-step procedure for both culturing and subsequent continuous drainage of the infected disc space. Materials and methods We retrospectively reviewed all cases of pyogenic spondylodiscitis admitted to our spine surgery unit during the past five years and treated with CT-guided percutaneous drain insertion into the infected disc space. All patients were followed until complete resolution of the infection. Results We retrieved electronic records of 12 patients, none presenting with neurological compression symptoms. Cultures taken at the time of drain insertion were positive in 10 patients (83.3%), much higher than the reported yield for needle aspiration (14–48%) and comparable to the yield of open biopsy. In all patients complete resolution of the infection was reached, determined by clinical, laboratory, and imaging parameters. Conclusions Our retrospective case series demonstrates the feasibility and effectiveness of intra-discal CT-guided drainage of an infected disc space. The procedure does not add much burden to current practice as disc-space sampling for culture is commonly performed anyway, and adds the benefit of direct drainage of the pus at its source.

Burkholderia cepacia is an important pathogen of humans in both immunocompromised and hospitalized patients. This uncommon pathogen is established to be the cause of pyogenic spondylodiscitis in only seven cases in the medical literature. Here, we report the cases of four patients who were diagnosed over two years period with Burkholderia cepacia spondylodiscitis and were successfully managed by appropriate antimicrobial treatment after open surgical biopsy was done for debridement and microbiological identification.

Study Design: Retrospective case series analysis. Objective: To identify relevant clinical and radiographic markers for patients presenting with infectious spondylo-discitis associated with spinal instability directly related to the infectious process. Methods: We evaluated patients presenting with de-novo intervertebral discitis or vertebral osteomyelitis /discitis (VOD) who initiated non-surgical treatment. Patients who failed conservative treatment and required stabilization surgery within 90 days were defined as “ failed treatment group” (FTG). Patients who experienced an uneventful course served as controls and were labeled as “ nonsurgical group” (NSG). A wide array of baseline clinical and radiographic parameters was retrieved and compared between 2 groups. Results: Overall 35 patients had initiated non-surgical treatment for VOD. 25 patients had an uneventful course (NSG), while 10 patients failed conservative treatment (“FTG”) within 90 days. Factors found to be associated with poorer outcome were intra-venous drug abuse (IVDA) as well as the presence of fever upon initial presentation. Radiographically, involvement of the same-level facets and the extent of caudal and rostral VB involvement in both MRI and CT were found to be significantly associated with poorer clinical and radiographic outcome. Conclusions: We show that clinical factors such as IVDA status and fever as well as the extent of osseous and posterior element involvement may prove to be helpful in favoring surgical treatment early on in the management of spinal infections.

Medical treatment with antibiotic therapy remains the mainstay of treatment for pyogenic spondylodiscitis (PS). Nevertheless, orthopaedic treatment is also very important in relieving pain, preventing neurological damage, and avoiding development of spinal deformities (e.g., scoliosis, kyphosis) due to spinal instability. Rigid thoracolumbosacral orthosis (TLSO) bracing is often needed in patients with PS, and average duration of treatment of 3 to 4 months. However, TLSO bracing can be poorly tolerated and limit ability of the patient to go back to a normal life. In 2004 our group developed an alternative surgical treatment to TLSO bracing by percutaneous posterior screw-rod bridge instrumentation of the infected level. This treatment allows early and free mobilization of the patients and is associated with faster recovery, lower pain scores and improved quality of life as previously reported. Herein, we report the clinical outcome of the first 3 patients who have completed the 10 years follow-up mark after the procedure. A case report is also described and details of the procedure are provided.

Background This study assessed the therapeutic effect of one-stage percutaneous endoscopic debridement and lavage (PEDL) combined with percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar pyogenic spondylodiscitis. Methods From March 2017 to October 2019, 25 patients diagnosed with pyogenic spondylodiscitis underwent PPSF followed by PEDL in our department. Biopsy specimens were examined for microorganisms and evaluated histopathologically. Clinical outcomes were assessed by physical examination, routine serological testing, visual analogue scale (VAS), Oswestry Disability Index (ODI), and imaging studies. Results All operations were successful, with no severe surgical complications in any patient and excellent incision healing. Causative bacteria were identified in most cases; Staphylococcus aureus was the most prevalent. The mean follow-up was 25.0 ± 3.8 (range: 20–32) months. Inflammatory markers showed that infection was controlled. The VAS and ODI improved significantly. At the last follow-up, magnetic resonance imaging showed that the infected lesions had disappeared. Conclusion PEDL supplementing PPSF may be useful for patients with single-level lumbar pyogenic spondylodiscitis, as it is minimally invasive, especially for patients who cannot undergo conventional open surgery due to poor health or advanced age.

Study design: Retrospective analysis of a single institution prospective, longitudinal database of spinal pyogenic infections. Diagnosis of pyogenic spondylodiscitis (PS) can be challenging. Although presenting symptoms are often non-specific, acute non-remitting axial back pain is the most striking feature. Nevertheless, several authors have reported on the uncommon occurrence of patients with PS without axial back pain. The aim of this study was to characterize presenting symptoms, causative agents, comorbidities, and treatment outcomes of patients presenting with painless pyogenic spondylodiscitis. A total of 214 patients diagnosed with PS were reviewed, patients were divided into two groups: patients presenting with no axial back pain (no pain group, n = 16), and patients presenting with axial back pain (control group, n = 198). Analyzed data comprised general demographics, presenting symptoms, comorbidities, spinal infection location, and amount of spinal involvement. While average age (62.4 vs. 65.0) and sex distribution was similar between the two groups, a significant diagnostic delay was noted in the control group (53 vs. 17 days, p &lt, 0.001). Patients in the no pain group were more likely IV drug abusers or have had liver failure/cirrhosis. Anatomic distribution (i.e., cervical vs thoracolumbar) of the infection did not differ between the two groups, but a higher number of post-surgical infections was noted in the no pain group (37.5 vs. 15.6%, p = 0.026). E. coli and Pseudomonas spp. were more commonly seen in no pain group patients, and mortality was also higher in this group (12.5 vs. 6.0%, p = 0.004).

Study Design: Retrospective cohort study. Objectives: Despite pyogenic spondylodiscitis potentially conferring significant morbidity, there is no consensus on optimal treatment. The Brighton Spondylodiscitis Score (BSDS) was developed to identify patients who would likely fail conservative management and therefore benefit from earlier surgical intervention. In this study, we attempt external validation of the BSDS. Methods: We carried out a retrospective review of all patients treated at our institution, 2010-2016, for pyogenic spondylodiscitis. 91 met inclusion criteria and 40 progressed to require surgical intervention. The BSDS was calculated for each patient allowing stratification into low-, moderate- and high-risk groups. Calibration and discrimination was assessed with ROC curve analysis and calibration plot. Results: Area under the curve (AUC) was 0.469 (0.22-0.71) in our external validation, compared with AUC 0.83 and 0.71 (CI 0.50-0.88) in the original study and test populations respectively. Only 60% of patients in the high-risk group required surgery, 50% in the moderate, and 38% of the low indicating poor calibration and predictive accuracy. Operative intervention was not higher overall in our cohort (44% vs. 32%, p = 0.14). We found greater rates of bacteraemia, more distal infection, and more advanced MRI findings in our cohort. The incidence of spondylodiscitis in our region is higher (4/100 000/year). Conclusion: We failed to externally validate the BSDS in our population which is likely a result of unique population characteristics and the inherently variable pathology associated with spondylodiscitis. Clinicians must be cautious in adopting treatment algorithms developed in other health care systems that may comprise significantly different patient and pathogen characteristics.

Pyogenic spondylodiscitis (PSD) is an infection of the intervertebral disk and adjacent vertebrae, which may also involve the paravertebral soft tissues. The incidence of PSD is increasing because of the growing number of elderly people and immunocompromised patients. Hematogeneous spread is by far the commonest route of spinal infection, due to the rich arterial supply of the vertebral body. PSD warrants early diagnosis and prompt treatment to prevent morbidity and mortality. Diagnosis is often challenging and requires a high index of clinical suspicion, blood and tissue cultures, appropriate imaging, and/or imaging-guided biopsy to enable an early diagnosis. This chapter aims to provide an overview of PSD, particularly its pathophysiology and imaging features. The roles of different imaging modalities such as radiography, computed tomography, magnetic resonance imaging (MRI), and nuclear scintigraphy are discussed, with a focus on MRI as the imaging modality of choice.

AIM This study aimed to reveal the efficiency of our surgical approach algorithm in patients with thoracolumbar pyogenic spondylodiscitis based on the involvement of anatomical structure. MATERIAL AND METHODS Data of patients who underwent debridement or stabilization surgery for thoracolumbar pyogenic spondylodiscitis from January 2012 to December 2018 were reviewed. Lumbar and thoracolumbar spondylodiscitis was classified into four stages based on anatomical involvement. Infection was limited in the disc space, which had not spread to the endplate in stage 1 and progressed as two-level corpus involvement of 1/2 of vertebral corpus bony destruction or as failed treatment in stage 4. Neurological function was evaluated using Frankel's grading postoperatively. Functional outcomes were categorized according to the Kirkaldy-Willis criteria. RESULTS The study included 39 patients, with a mean age of 58.2 years. Of these patients, 10, 12, 13, and 4 had stages 1, 2, 3, and 4 spondylodiscitis, respectively. The mean follow-up period was 60.2 (12-184) months. All patients with stages 1 and 2 spondylodiscitis had grade E injury; 2 and 10 patients with stage 3 had grades D and E injuries, respectively; two patients with stage 4 had grade D injury and two had grade E injury at the last follow-up. Moreover, 100%, 84.6%, and 50% of the patients with stages 1 and 2, 3, and 4 spondylodiscitis achieved good or excellent results, respectively. CONCLUSION The choice of the surgical technique depends on the destruction severity at the adjacent vertebral corpus. Surgical staging system for spondylodiscitis is useful and reliable in choosing appropriate surgical techniques.

Although rare, spondylodiscitis is the main manifestation of hematogeneous osteomyelitis in patients aged more than 50 years. In this chapter, we discuss the pathophysiology of spinal infections. We review the vascular supply of the spine and its development with age, which is important in understanding the typical patterns of infection in adults and children. Routes of pathogen spread are detailed, with a review of the literature. We identify specificities of pathophysiology in the most common causes of spinal infection, namely, pyogenic and tuberculous spondylodiscitis.

Background:Due to the unspecific symptoms of spondylodiscitis (SpD), an early radiological examination is necessary. However, controversially discussed is the need for an magnetic resonance imaging of the entire spine to exclude multisegmental infections and to determine the required surgical interventions. The aims of this study were to assess the incidence of multilevel non-contiguous pyogenic SpD and compare comorbidities, pain symptoms, and subsequent surgical strategies between unifocal (uSpD) and multifocal (mSpD) SpD. Methods:We retrospectively evaluated the data of patients with confirmed, surgically treated, pyogenic SpD who had received a total spine MRI in a single spine center between 2016 and 2018. MRI findings were classified according to Pola-classification and demographics, duration of clinical symptoms (pain and neurology) and Charlson Comorbidity-Index (CCI) results were compared between uSpD und mSpD groups. Surgical therapy was evaluated in patients with mSpD. Results: uSpD was detected by MRI in 69 of 79 patients (87 %). Of these, mSpD was detected in 10 patients (13%) with 21 infected segments (cervical and/ or thoracic and/ or lumbar region). Age and CCI were similar between uSpD and mSpD and 24 of all SpD regions were clinically unapparent. All patients with uSpD were treated operatively. In seven patients with mSpD, all infected levels of the spine were treated surgically in a one-stage procedure; one patient had a two-stage procedure and one patient had surgery at the lumbar spine, and an additional infected segment of the upper thoracic spine was treated conservatively. One patient died before a planned two-stage procedure was performed. Conclusions:Due to mSpD being found in approximately 13% of SpD cases, and considering the risk of overlooking an mSpD case, MRI imaging of the total spine is recommended. The detection of multiple infection levels can have an impact on the therapeutic strategy chosen.

Study Design: Diagnostic study, level of evidence III. Objective: Pyogenic spondylodiscitis can cause deformity, neurological compromise, disability, and death. Recently, a new classification of spondylodiscitis based on magnetic resonance imaging was published. The objective of this study is to perform an independent reliability analysis of this new classification. Methods: We selected 35 cases from our database of different spine centers in Latin America and from the literature; 8 observers evaluated the classification and graded the scenarios according to the methodological grading of the classification developed by Pola et al. Cases were sent to the observers in a random sequence after 3 weeks to assess intraobserver reliability. The interobserver and intraobserver reliabilities were performed with Fleiss and Cohen statistics, respectively. Results: The overall Fleiss κ value for interobserver agreement was substantial, with 0.67 (95% CI = 0.43-0.91) in the first reading and 0.67 (95% CI = 0.45-0.89) in second reading for the main types of classification. The Cohen κ value for intraobserver agreement was also substantial, with 0.68 (95% CI = 0.45-0.92). The interobserver agreement analysis for the subtypes of this classification was overall substantial, with 0.60 (95% CI = 0.37-0.83) in the first reading and 0.61 (95% CI = 0.41-0.81) in the second reading. The overall intraobserver agreement for subtypes of the classification was also substantial, with 0.63 (95% CI = 0.34-0.93). Conclusion: The new classification developed by Pola et al showed substantial interobserver and intraobserver agreements. More studies are required to validate the usefulness of this classification especially in clinical practice.

Introduction Pyogenic spondylodiscitis is a bacterial infection affecting the intervertebral disc and its adjacent vertebrae. Although relatively rare, it is a challenging medical disease with a poor prognosis that requires immediate diagnosis and treatment with suitable antibiotics. Aim To evaluate the clinical outcome of minimally invasive spine surgery (MIS) for pyogenic spondylodiscitis. Material and methods The retrospective study cohort consisted of 10 consecutive patients who had undergone MIS decompression and/or discectomy for thoracic or lumbar pyogenic spondylodiscitis in our hospital. Data including patient characteristics, symptoms, visual analog scale (VAS) score, surgical approach and postoperative outcomes were obtained for retrospective analysis. Results Between January 2005 and December 2013, 10 patients underwent MIS decompression in the Department of Orthopedics in our medical university. Seven of these patients had lumbar infections and 3 had thoracic infections. All 10 patients had improved VAS scores immediately after surgery and after discharge. The VAS score (respectively on postoperative day 1 and day 7) suggested that the patients in this study had significantly less pain than preoperatively (day 1: 5 vs. 9, p < 0.001; day 7: 2.9 vs. 9, p < 0.001). The organism was obtained in 10 (100%) patients by the operative cultures. All patients achieved an excellent clinical recovery without the need for further spine surgery. All patients underwent postoperative imaging during follow-up and showed complete resolution or dramatically improved magnetic resonance imaging changes. Conclusions Minimally invasive spine surgery is a safe and effective surgical approach for pyogenic spondylodiscitis.

Recent studies have consistently reported the safety and effectiveness of early spinal instrumentation for pyogenic spondylodiscitis. However, none of these studies investigated the recurrence rate or associated factors based on this specific group of patients. Recurrence prediction models that are not based on a homogenous cohort of patients undergoing early spinal instrumentation show theoretical limitations for clinical use. A nationwide, population-based, retrospective cohort study using a claims database was planned to investigate the recurrence rate and its associated factors in patients who underwent early instrumented spinal fusion surgery for pyogenic spondylodiscitis. We used data from the Korean National Health Insurance claims database collected between 2014 and 2018. A total of 2148 patients who underwent early (within 6 weeks after the diagnosis) instrumented spinal fusion surgery for pyogenic spondylodiscitis were included, including 1925 patients (90%) without recurrence and 223 patients (10%) with recurrence. Logistic regression models were used to identify factors associated with recurrence, and sensitivity analysis was performed according to two different definitions for recurrence: shorter (2 weeks or more) and longer (6 weeks or more) periods of antibiotic therapy for recurrence. The recurrence rates in our cohort were 14.1%, 10.4%, and 8.0% at 2, 4, and 6 weeks, respectively, in relation to the duration of antibiotic treatment for recurrence. We identified age 60–69 years (OR = 2.42), age > 70 years (OR = 2.29), posterior thoracic approach (OR = 1.85), multiple surgical approaches (OR = 4.17), use of a cage (OR = 1.66), transfusion (OR = 2.55), antibiotics for resistant organisms (OR = 2.55), and systemic steroid treatment over 2 weeks (OR = 2.27) as the factors associated with recurrence. The recurrence rates and associated factors from our first population-based and the largest clinical study can be practically used as a reasonable reference and provide clinicians with an acceptable tool for the comprehensive risk assessment for recurrence after early spinal instrumentation for pyogenic spondylodiscitis.

Spine infection is unfortunately a common occurrence, especially in susceptible patient populations. Differentiating infection from other non-infectious disease processes can be extremely difficult both clinically and on imaging. This chapter will review imaging of pyogenic spondylodiscitis, tuberculous spondylodiscitis, fungal spondylodiscitis, infectious sacroiliitis, and epidural abscesses with focus on the unique imaging features differentiating these conditions from non-infectious disease processes in the spine.

An 81-year-old man presented with severe back pain. Magnetic resonance imaging detected L5/S discitis without signs of epidural abscess. Punctures of the disc revealed that the causative organism was Gemella morbillorum (G. morbillorum), which is part of the normal flora of the oral cavity and an uncommon causative pathogen of spondylodiscitis. The E-test method was useful for rapid susceptibility testing. Intravenous penicillin G treatment was effective, and the patient recovered without surgery.

ObjectiveThe primary objective was to assess the characteristics and prognosis of pyogenic spondylodiscitis (PS) in patients with infective endocarditis (IE). The secondary objectives were to assess the factors associated with occurrence of PS.MethodsProspective case–control bi-centre study of 1755 patients with definite IE with (n=150) or without (n=1605) PS. Clinical, microbiological and prognostic variables were recorded.ResultsPatients with PS were older (mean age 69.7±18 vs 66.2±14; p=0.004) and had more arterial hypertension (48% vs 34.5%; pStreptococcus gallolyticus were more frequent (24% vs 12% and 24% vs 11%; p18F-FDG PET/CT in 56 patients. In-hospital (16% vs 13.5%, p=0.38) and 1-year (21% vs 22%, p=0.82) mortalities did not differ between patients with or without PS.ConclusionsPS is a frequent complication of IE (8.5% of IE), is observed in older hypertensive patients with enterococcal or S. gallolyticus IE, and has a similar prognosis than other forms of IE. Since PS is associated with specific management, multimodality imaging including MRI, CT and PET/CT should be used for early diagnosis of this complication of endocarditis.

Pyogenic spondylodiscitis (PS) is a debilitating condition laden with orthopedic and neurological complications. The choice of the best step in management is often delayed due to the controversy encompassing its multiple facets. Several classification systems were proposed in the literature to define optimal management; however, consensus was not achieved.The aim of this study was to review the literature and critically appraise the classification systems of PS and the rationale behind the classification criteria.A literature search was conducted in PubMed. Titles and abstracts of articles were searched using different synonyms of spondylodiscitis and its classification. No restrictions regarding language of publication or date of publication were applied.A total of 43 papers with 5 encompassing 3 main classifications were found in the literature. These classifications were overlapping but different. They encompassed neurologic deficits, abscess formation and segmental instability, laboratory parameters and morphological changes in magnetic resonance imaging (MRI) as the most important factors used to classify PS, assess the severity and guide treatment.The current classification schemes overlap and encompass the most clinically relevant factors; however, some could be too complex for interdisciplinary clinical practice and do not adequately address unique entities, such as PS of the cervical spine, anterolisthesis and retrolisthesis. Most importantly, some criteria must be utilized in concert with recently published guidelines and should be re-assessed for validity and reliability. A uniform orthopedic parlance is required to optimize the management of this debilitating and life-threatening condition.HINTERGRUND: Die pyogene Spondylodiszitis (PS) ist eine lebensbedrohliche Erkrankung mit zahlreichen orthopädischen und neurologischen Komplikationen. Die Wahl des besten Therapieschrittes wird aufgrund der facettenreichen Darstellung des Krankheitsbilds häufig verzögert. In der Literatur wurden mehrere Klassifikationssysteme zur Entscheidungsfindung vorgeschlagen, um ein optimales Therapie-Management zu definieren. Ein Konsens wurde jedoch nicht erreicht.Das Ziel dieser Studie ist es, die Literatur bezüglich der vorhandenen Klassifikationen der PS zu überprüfen und die Klassifizierungsparameter kritisch zu bewerten.Eine Literaturrecherche wurde mit PubMed durchgeführt. Titel und Abstracts von Artikeln wurden mit verschiedenen Synonymen der Spondylodiszitis und ihrer Klassifikation durchsucht. Sowohl die Veröffentlichungssprache als auch das Veröffentlichungsdatum stellten kein Ausschlusskriterium dar.Iinsgesamt wurden 43 Artikel gefunden, von denen 5 Arbeiten 3 verschiedene Klassifikationen aufwiesen. Diese Klassifikationen überschneiden sich, auch wenn sie sich zum Teil unterscheiden. Sie umfassen die wichtigsten Parameter wie das neurologische Defizit, die Abszessbildung und die segmentale Instabilität sowie Laborparameter und morphologische Veränderungen in der Magnetresonanztomographie (MRT) zur Klassifizierung der PS, zur Einschätzung des Schweregrades und zur therapeutischen Entscheidungsfindung.Die aktuell publizierten Klassifikationen zeigen bezüglich des Aufbaus Überlappungen und umfassen die klinisch relevantesten Parameter. Einige dieser Klassifikationen könnten jedoch für die interdisziplinäre klinische Praxis zu komplex und im klinischen Alltag schwere zu handhaben sein. Auch werden einzelne Entitäten wie z. B. die PS der Halswirbelsäule, die Antero- und die Retrolisthese nicht adressiert. Am wichtigsten ist, dass einige der enthaltenen Kriterien in Übereinstimmung mit den kürzlich veröffentlichten Leitlinien verwendet werden müssen und auf ihre Validität und Reliabilität überprüft werden sollten. Eine einheitliche orthopädische Klassifikation ist erforderlich, um das Management dieser lebensbedrohlichen Erkrankung zu optimieren.

Purpose: To observe the clinical curative effect of continuous epidural irrigation combined with posterior debridement and posterior lumbar inter-body fusion with instrumentation for the therapy of single-segment lumbar pyogenic spongdylodiscitis. Methods: From June 2010 to November 2013, surgical treatment was performed in 18 patients with pyogenic spondylodiscitis. The surgical indications were progressive biomechanical instability, epidural abscesses, deterioration of neurologic status, and intractable back pain. All these patients received posterior decompression with posterior instrumentation, debridement of infected tissue, and inter-body fusion. Visual Analogue Scale (VAS) scores were used to assess clinical outcomes. The neural function was evaluated by the Frankel grading system. Laboratory and radiologic results were recorded during clinical follow-up for at least one year. Results: The average follow-up period was 18 months after the operation. The VAS scores decreased from an average of 7.1 points before the procedure to 2.6 points after operation. The neurologic deficits of all the patients were recovered to Frankel grade E. All of the examined laboratory parameters were normalized gradually. Imaging-documented fusion was achieved in each patient, and no implants failure was noted. No patients showed any evidence of recurrence or persistence of infection. Conclusion: In carefully selected patients, single-segment lumbar pyogenic spondylodiscitis can be cured successfully with continuous epidural irrigation and drainage combined with posterior debridement and posterior lumbar inter-body fusion. Instrumentation could provide immediate stability and reconstruction of the spine column, and the presence of instrumentation did not result in any persistence or recurrence of infection. Continuous epidural irrigation and drainage is an effective method facilitating the elimination of residual infection.

Summary Background Infectious spondylodiscitis is characterized by the involvement of two adjacent vertebrae and the intervening disc. Incidence rate of the disease is estimated at 0.4–2 cases per 100000 per year. Staphylococcus aureus is the most common infectious agent causing pyogenic spondylodiscitis. Non-pyogenic infections of the spine are most frequently caused by Mycobacterium tuberculosis, and fungi. Clinical symptoms are nonspecific. Early diagnosis and appropriate treatment can prevent unfavorable irreversible sequela for the patient. Significant developments in techniques of imaging of pathological tissues raised expectations among the clinicians regarding possibility to distinguish between tuberculous spondylodiscitis and pyogenic spondylodiscitis on MR images. The aim of this study was to identify and differentiate between features of tuberculous and pyogenic spondylodiscitis on MR images. Material/Methods We performed retrospective analysis of MR images obtained from 34 patients with confirmed spondylodiscitis (18 with pyogenic spondylodiscitis, and 16 with tuberculous spondylodiscitis). Data acquisition was performed using 1.5 T MRI scanners where images were obtained using similar protocols. T2 TIRM and T1-weighted images with and without contrast enhancement were subject to assessment in coronal, axial and sagittal planes. Results Characteristic features of pyogenic spondylodiscitis include: involvement of the lumbar spine, ill-defined paraspinal abnormal contrast enhancement, diffuse/homogeneous contrast enhancement of vertebral bodies, low-grade destruction of vertebral bodies, hyperintense/homogeneous signal from the vertebral bodies on T2 TIRM images. Prevailing features of tuberculous spondylodiscitis included: involvement of the thoracic spine, involvement of 2 or more adjacent vertebral bodies, severe destruction of the vertebral body, focal/heterogeneous contrast enhancement of vertebral bodies, heterogeneous signal from the vertebral bodies on T2 TIRM images, well-defined paraspinal abnormal contrast enhancement, paraspinal and epidural abscesses, meningeal enhancement at the affected spine level. Conclusions Comparison of MR images of patients diagnosed with pyogenic spondylodiscitis and tuberculous spondylodiscitis allowed identification of individual characteristics for preliminary differentiation between TB and infectious spondylodiscitis and thereby enabling proper treatment.

Background:Infectious spondylodiscitis is a life-threatening infection of the intervertebral disc and adjacent vertebrae that can be caused by a variety of microorganisms. Our country is at intermediate endemicity for Tuberculosis.Objectives:To compare the clinical, biological, radiological characteristics, management and prognosis of pyogenic versus tuberculous spondylodiscitis.Methods:Retrospective study of 89 patients admitted to our department over a period of 20 years [1998-2018]. The diagnosis of spondylodiscitis was made based on clinical, biological, radiological and bacteriological data.Results:The average age of the patients was 56.1 years. There were 46 men (51.6%) and 43 women (48.4%) with a female predominance during tuberculous spondylodiscitis (57.1%) versus 26.9% during pyogenic spondylodiscitis (p = 0.009).Diabetes was more frequent during pyogenic spondylodiscitis but with no statistically significant difference (p = 0.4). The evolution time was statistically greater during tuberculous spondylodiscitis (p Hyperleukocytosis was noted more frequently in the pyogenic group than in the tuberculosis group (p=0.03), while the increase in sedimentation rate was not significantly different between the two groups (90 mm/h and 76 mm/h, respectively, p=0.1). We found no statistically significant difference regarding the site of spondylodiscitis.Radiologically, the frequency of para-vertebral and psoas abscesses, epiduritis and the presence of spinal cord compression were similar in the two groups (p=0.2; p=0.1 and p=0.1, respectively), whereas mirrored geodes were more frequent during tuberculosis (p = 0.04).Surgical and interventional treatments (percutaneous sampling, abscess drainage) were more frequently noted during pyogenic spondylodiscitis, but without significant difference (p=0.2). The occurrence of immediate complications was more frequent during tuberculosis but without a statistically significant difference (p=0.2).Conclusion:In our series, patients with tuberculous spondylodiscitis tend to have a chronic pattern of progression and more often an impaired general condition. However, there was no significant difference in the presence of abscess, epiduritis and the occurrence of complications between tuberculous spondylodiscitis and pyogenic spondylodiscitis.Disclosure of Interests:None declared

Aims The aim of this study was to evaluate the outcome of spinal instrumentation in haemodialyzed patients with native pyogenic spondylodiscitis. Spinal instrumentation in these patients can be dangerous due to rates of complications and mortality, and biofilm formation on the instrumentation. Patients and Methods A total of 134 haemodialyzed patients aged more than 50 years who underwent surgical treatment for pyogenic spondylodiscitis were included in the study. Their mean age was 66.4 years (50 to 83); 66 were male (49.3%) and 68 were female (50.7%). They were divided into two groups according to whether spinal instrumentation was used or not. Propensity score matching was used to attenuate the potential selection bias. The outcome of treatment was compared between these two groups. Results A total of 89 patients (66.4%) underwent non-instrumented surgery and 45 (33.5%) underwent instrumented surgery. There were no significant differences in the rates of postoperative complications, except for an increased rate of wound problems in the instrumented group, which was found in the unmatched cohorts (p = 0.034). There were no significant differences in the rate of recurrent infections (p = 0.328 for the unmatched cohort; p = 0.269 for the matched cohort) and mortality rate, including in-hospital (p = 0.713 for the unmatched cohort; p = 0.738 for the matched cohort) and one-year rates (p = 0.363 for the unmatched cohort; p = 0.787 for the matched cohort), between the groups. However, the interval between the initial diagnosis and the first recurrence was significantly longer in the instrumented group (p = 0.008 for the unmatched cohort; p = 0.032 for the matched cohort). Conclusion Instrumented surgery for haemodialyzed patients with pyogenic spondylodiscitis showed similar outcomes, including recurrence and mortality, to non-instrumented surgery, despite the instrumented group having more severe neurological deficit, a larger number of involved levels, and increased kyphotic angle.

Background Most guidelines recommend 6 to 12 weeks of parenteral antibiotic treatment for pyogenic spondylodiscitis. When surgical debridement is adequately performed, further intravenous antibiotic treatment duration can be reduced than that of conservative treatment alone theoretically. However, the appropriate duration of post-surgical parenteral antibiotic treatment is still unknown. This study aimed to identify the risk factors of recurrence and evaluate the appropriate duration after surgical intervention. Methods This 3-year retrospective review included 102 consecutive patients who were diagnosed with pyogenic spondylodiscitis and underwent surgical intervention. Recurrence was defined as recurrent signs and symptoms and the need for another unplanned parenteral antibiotic treatment or operation within one year. This study included two major portions. First, independent risk factors for recurrence were identified by multivariable analysis, using the database of demographic information, pre-operative clinical signs and symptoms, underlying illness, radiographic findings, laboratory tests, intraoperative culture results, and treatment. Patients with any one of the risk factors were considered high-risk; those with no risk factors were considered low-risk. Recurrence rates after short-term (≤3 weeks) and long-term (> 3 weeks) parenteral antibiotic treatment were compared between the groups. Results Positive blood culture and paraspinal abscesses were identified as independent risk factors of recurrence. Accordingly, 59 (57.8%) patients were classified as low-risk and 43 (42.2%) as high-risk. Among the high-risk patients, a significantly higher recurrence rate occurred with short-term than with long-term antibiotic therapy (56.2% vs. 22.2%, p = 0.027). For the low-risk patients, there was no significant difference between short-term and long-term antibiotic therapy (16.0% vs. 20.6%, p = 0.461). Conclusions The appropriate duration of parenteral antibiotic treatment in patients with pyogenic spondylodiscitis after surgical intervention could be guided by the risk factors. The duration of postoperative intravenous antibiotic therapy could be reduced to 3 weeks for patients without positive blood culture or abscess formation.

OBJECTIVEThe incidence of patients with pyogenic spinal infection is increasing. In addition to treatment of the spinal infection, early diagnosis of and therapy for coexisting infections, especially infective endocarditis (IE), is an important issue. The aim of this study was to evaluate the proportion of coexisting IE and the value of routine transesophageal echocardiography (TEE) in the management of these patients.METHODSThe medical history, laboratory data, radiographic findings, treatment modalities, and results of TEE of patients admitted between 2007 and 2017 were analyzed.RESULTSDuring the abovementioned period, 110 of 255 total patients underwent TEE for detection of IE. The detection rate of IE between those patients undergoing and not undergoing TEE was 33% and 3%, respectively (p < 0.0001). Thirty-six percent of patients with IE needed cardiac surgical intervention because of severe valve destruction. Chronic renal failure, heart failure, septic condition at admission, and preexisting heart condition were significantly associated with coexisting IE. The mortality rate in patients with IE was significantly higher than in patients without IE (22% vs 3%, p = 0.002).CONCLUSIONSTEE should be performed routinely in all patients with spondylodiscitis.

Objective The aim of this study was to compare the clinical, radiologic, and functional outcomes of a 1-stage posterior treatment versus a 2-stage posterior-anterior treatment in patients with pyogenic thoracic spondylodiscitis. Methods A 1-stage posterior debridement, stabilization, and fusion with titanium-coated polyetheretherketone (PEEK) or mesh cage through a dorsolateral approach was performed in group A. A 2-stage procedure with initial posterior stabilization and debridement and second-stage fusion with a PEEK cage or mesh cage was performed with an anterior approach in group B. Clinical outcomes included Oswestry Low Back Pain Disability Questionnaire and visual analog scale score. Radiologic outcomes included fusion rate and kyphotic angle correction. Secondary variables included pathogens, complications, blood loss, and operative time. Results One-level spondylodiscitis was treated surgically in the thoracic spine of 47 patients: 25 patients in group A and 22 patients in group B. The most frequent segment was T12-L1 (27%). There was a significantly longer operative time and greater blood loss (P > 0.001) in group B. At last follow-up, sagittal profile reconstruction was significantly better (P > 0.05) in group B. Both groups showed similar radiologic results with fusion in 92% of cases. Improved clinical outcomes, pain, and quality of life were achieved in both groups with no significant differences between the 2 groups. Conclusions Better reconstruction of the sagittal profile was achieved in the posterior-anterior–treated group, but this did not affect the clinical outcome. No significant differences were found in the clinical and functional outcomes between the 2 groups. Posterior-anterior combined treatment should be considered in cases of large anterior defects if a posterior reconstruction is inadequate.

Summary Objectives Smaller studies indicate that the incidence of pyogenic spondylodiscitis is increasing, possible related to a growing elderly population. Data supporting this is sparse, and we therefore studied patient characteristics and changes in spondylodiscitis incidence 1995–2008. Methods In a population-based study we identified all patients aged ≥18 years treated for pyogenic spondylodiscitis in Funen County, Denmark (population 483 123). Annual incidences were determined. Demographics, symptoms and diagnostic methods were recorded. Results We found 192 cases: median age 66.6 years; 57.3% men; 76.6% culture positive cases . Staphylococcus aureus was the most common pathogen (55.1%). During 1995–2008 the overall incidence, incidence of culture negative cases, and incidence of cases due to S. aureus increased 2.2–5.8, 0.3–1.8, and 1.6–2.5 cases per 100 000 person years, respectively. The elderly had the highest incidence compared to those aged ≤70 years (rate ratio for men 5.9 (95% CI: 4.2–8.5) and for women 3.5 (95% CI: 2.3–5.3)). Conclusions During 1995–2008 the overall incidence of S. aureus and culture negative cases of spondylodiscitis increased and remained highest among the elderly. Whether the increase is real or is a result of improved diagnostic methods and workup remains unknown.

Background Context A spinal infection is a serious problem for a spine surgeon, and there is currently much debate regarding how best to treat pyogenic spondylodiscitis using antibiotics and the instrumentations that have been developed to date. Purpose The purpose of this study was to determine which method is better for treating pyogenic spondylodiscitis. Study Design A retrospective chart review was performed. Patient Sample Thirty-one patients with pyogenic spondylodiscitis underwent surgical treatment between 2000 and 2016 at the authors' institution. Outcome Measures Clinical outcomes were assessed using a visual analog scale (VAS). We measured translation and rotation on flexion and extension X-rays to identify instability. Methods Patients were divided into two groups: Group I, decompression group; Group II, decompression plus fusion group. Group I exhibited no instability according to a preoperative radiographic study, whereas Group II exhibited instability. Both groups were compared with respect to demographics and laboratory findings, including tests to determine C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR), organisms, and the total duration of antibiotic treatment after the operation. We compared the results of the preoperative, postoperative, and last follow-up radiographic examinations of the sagittal alignment of the infected segment. This study was supported by a clinical research fund (4,500 dollars) from the National Health Insurance Service, Ilsan Hospital. Results A total of 31 patients were included; 22 (71%) were in Group I and 9 (29%) were in Group II. On radiological examination, the mean preoperative translation and rotation values in Group I were 2.45±1.22 mm and 5.64±1.98°, and in Group II were 5.35±1.65 mm and 12.01±4.22°. At the last follow-up, the mean translation and rotation values in Group I were 1.95±1.75 mm and 2.69±1.61°, and in Group II were 1.77±1.02 mm and 3.44±2.07°. Both Groups I and II exhibited stability after the operation. No differences were detected in preoperative ESR and CRP levels between the two groups. Group I, compared with Group II, experienced a shorter duration of treatment with antibiotics and normalization of ESR and CRP levels after the operation and a shorter hospitalization period. Conclusions If the appropriate antibiotics are administered quickly when there is no instability, decompression alone is effective; however, if instability is detected, decompression plus fusion can be used to achieve stability.

To retrospectively describe the feasibility and efficacy of CT fluoroscopy-guided transsacral intervertebral drainage for pyogenic spondylodiscitis at the lumbosacral junction with a combination of two interventional radiological techniques-CT-guided bone biopsy and abscess drainage.Three patients with pyogenic spondylodiscitis at the lumbosacral junction were enrolled in this study between July 2013 and December 2015. The procedure of CT fluoroscopy-guided transsacral intervertebral drainage for pyogenic spondylodiscitis at the lumbosacral junction was as follows: the sacrum at S1 pedicle was penetrated with an 11-gauge (G) bone biopsy needle to create a path for an 8-French (F) pigtail drainage catheter. The bone biopsy needle was withdrawn, and an 18-G needle was inserted into the intervertebral space of the lumbosacral junction. Then, a 0.038-inch guidewire was inserted into the intervertebral space. Finally, the 8-F pigtail drainage catheter was inserted over the guidewire until its tip reached the intervertebral space. All patients received six-week antibiotics treatment.Successful placement of the drainage catheter was achieved for each patient without procedural complications. The duration of drainage was 17-33 days. For two patients, specific organisms were isolated; thus, definitive medical therapy was possible. All patients responded well to the treatment.CT fluoroscopy-guided transsacral intervertebral drainage for pyogenic spondylodiscitis at the lumbosacral junction is feasible and can be effective with a combination of two interventional techniques-CT fluoroscopy-guided bone biopsy and abscess drainage.

The incidence of pyogenic spondylodiscitis is low but has been steadily increasing in recent years. To date there has been no consensus concerning selection of the appropriate treatment, management and strategies and the recommendations for an operative strategy are still a highly controversial issue. In the literature a few statements have been published concerning therapeutic decision-making in pyogenic spondylodiscitis. The classification given in this article is based on clinical experience and retrospective data analysis considering the degree of segmental bony destruction, grade of kyphosis and instability, epidural involvement of the disease and neurological deficits, which are pivotal for therapeutic decision-making. The therapeutic procedure can be defined based on this classification.

BackgroundReports on CT-guided percutaneous drainage within the intervertebral space for pyogenic spondylodiscitis with a secondary psoas abscess are limited.PurposeTo evaluate CT-guided percutaneous drainage within the intervertebral space for pyogenic spondylodiscitis and a secondary psoas abscess in which the two sites appear to communicate.Material and MethodsEight patients with pyogenic spondylodiscitis and a secondary psoas abscess showing communication with the intradiscal abscess underwent CT-guided percutaneous drainage within the intervertebral space. The clinical outcome was retrospectively assessed.ResultsAn 8-French pigtail catheter within the intervertebral space was successfully placed in all patients. Seven patients responded well to this treatment. The one remaining patient who had developed septic shock before the procedure died on the following day. The mean duration of drainage was 32 days (13–70 days). Only one patient with persistent back pain underwent surgery for stabilization of the spine after the improvement of inflammation. Among seven patients responding well, long-term follow-up (91–801 days, mean 292 days) was conducted in six patients excluding one patient who died of asphyxiation due to aspiration unrelated to the procedure within 30 days after the procedure. In these six patients, no recurrence of either pyogenic spondylodiscitis or the psoas abscess was noted.ConclusionCT-guided percutaneous drainage within the intervertebral space can be effective for patients with pyogenic spondylodiscitis and a secondary psoas abscess if the psoas abscess communicates with the intradiscal abscess.