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Objective: This study aimed to distinguish tuberculous spondylodiscitis (TS) from pyogenic spondylodiscitis (PS) based on laboratory, magnetic resonance imaging (MRI) and computed tomography (CT) findings. Further, a novel diagnostic model for differential diagnosis was developed. Methods: We obtained MRI, CT and laboratory data from TS and PS patients. Predictive models were built using binary logistic regression analysis. The receiver operating characteristic curve was analyzed. Both internal and external validation was performed. Results: A total of 81 patients with PS (n = 46) or TS (n = 35) were enrolled. All patients had etiological evidence from the focal lesion. Disc signal or height preservation, skip lesion or multi segment (involved segments ≥ 3) involvement, paravertebral calcification, massive sequestra formation, subligamentous bone destruction, bone erosion with osteosclerotic margin, higher White Blood Cell Count (WBC) and positive result of tuberculosis infection T cell spot test (T-SPOT.TB) were more prevalent in the TS group. A diagnostic model was developed and included four predictors: WBC<7.265 * (10^9/L), skip lesion or involved segments ≥ 3, massive sequestra formation and subligamentous bone destruction. The model showed good sensitivity, specificity, and total accuracy (91.4%, 95.7%, and 93.8%, respectively); the area under the receiver operating characteristic curve (AUC) was 0.981, similar to the results of internal validation using bootstrap resampling (1000 replicates) and external validation set, indicating good clinical predictive ability. Conclusions: This study develop a good diagnostic model based on both CT and MRI, as well as laboratory findings, which may help clinicians distinguish between TS and PS. [ABSTRACT FROM AUTHOR]

Objective This study aimed to compare and analyze differences in clinical and magnetic resonance imaging (MRI) findings between tuberculous spondylodiscitis (TbS) and pyogenic spondylodiscitis (PyS), and to develop and validate a simplified multiparameter MRI-based scoring system for differentiating TbS from PyS. Methods We compared predisposing factors in 190 patients: 123 with TbS and 67 with PyS, confirmed by laboratory tests, culture, or pathology. Data encompassing patient demographics, clinical characteristics, laboratory results, and MRI findings were collected between 2015 and 2020. Data were analyzed using logistic regression methods, and selected coefficients were transformed into an MRI-based scoring system. Internal validation was performed using bootstrapping method. Results Univariate analysis revealed that the significant risk factors associated with TbS included thoracic lesions, vertebral destruction > 50%, intraosseous abscess, thin-walled abscess, well-defined paravertebral abscess, subligamentous spreading, and epidural abscess. Multivariate analysis revealed that only thoracic lesions, absence of epidural phlegmon, subligamentous spreading, intraosseous abscesses, well-defined paravertebral abscesses, epidural abscesses, and absence of facet joint arthritis were independent predictive factors for TbS (all p < 0.05). These potential predictors were used to derive an MRI scoring system. Total scores ≥ 14/29 points significantly predicted the probability of TbS, with a sensitivity of 97.58%, specificity of 92.54%, and an area under the curve of 0.96 (95% confidence interval, 125.40–3,257.95). Conclusion This simplified MRI-based scoring system for differentiating TbS from PyS helps guide appropriate treatment when the causative organism is not identified.

The incidence of spontaneous or primary spondylodiscitis has been increasing over the years, affecting the aging population with multiple comorbidities. Several conditions influencing treatment outcomes stand out, such as diabetes mellitus, renal insufficiency, cardiovascular and respiratory dysfunction, and malnutrition. Due to these, the question arises regarding properly managing their current conditions and pre-existing disease states. Treatment plans must consider all concomitant comorbidities rather than just the infectious process. This can be done with the help of multidisciplinary teams to provide comprehensive care for patients with pyogenic spondylodiscitis. To date, there is no article regarding comprehensive medicine for spontaneous pyogenic spondylodiscitis; hence, this paper reviews the evidence available in current literature, recognizes knowledge gaps, and suggests comprehensive care for treating patients with spinal infections. Pre-requisites for implementing multidisciplinary teams include leadership, administrative support, and team dynamics. This group comprises an appointed leader, coordinator, and different subspecialists, such as orthopedic surgeons, infectious disease specialists, internists, rehabilitation doctors, psychiatrists, microbiologists, radiologists, nutritionists, pharmacologists, nurses, and orthotists working together with mutual trust and respect. Employing collaborative teams allows faster time for diagnosis and improves clinical outcomes, better quality of life, and patient satisfaction. Forefront communication is clear and open between all team members to provide holistic patient care. With these in mind, the need for employing multidisciplinary teams and the feasibility of its implementation emerges, showing a promising and logical path toward providing comprehensive care in managing multimorbid patients with pyogenic spondylodiscitis.

Objective: This study aimed to compare and analyze differences in clinical and magnetic resonance imaging (MRI) findings between tuberculous spondylodiscitis (TbS) and pyogenic spondylodiscitis (PyS), and to develop and validate a simplified multiparameter MRI-based scoring system for differentiating TbS from PyS. Methods: We compared predisposing factors in 190 patients: 123 with TbS and 67 with PyS, confirmed by laboratory tests, culture, or pathology. Data encompassing patient demographics, clinical characteristics, laboratory results, and MRI findings were collected between 2015 and 2020. Data were analyzed using logistic regression methods, and selected coefficients were transformed into an MRI-based scoring system. Internal validation was performed using bootstrapping method. Results: Univariate analysis revealed that the significant risk factors associated with TbS included thoracic lesions, vertebral destruction > 50%, intraosseous abscess, thin-walled abscess, well-defined paravertebral abscess, subligamentous spreading, and epidural abscess. Multivariate analysis revealed that only thoracic lesions, absence of epidural phlegmon, subligamentous spreading, intraosseous abscesses, well-defined paravertebral abscesses, epidural abscesses, and absence of facet joint arthritis were independent predictive factors for TbS (all p < 0.05). These potential predictors were used to derive an MRI scoring system. Total scores ≥ 14/29 points significantly predicted the probability of TbS, with a sensitivity of 97.58%, specificity of 92.54%, and an area under the curve of 0.96 (95% confidence interval, 125.40–3,257.95). Conclusion: This simplified MRI-based scoring system for differentiating TbS from PyS helps guide appropriate treatment when the causative organism is not identified. [ABSTRACT FROM AUTHOR]

Background Infectious spondylodiscitis is a debilitating condition and evidence-based medicine dictates confirming the diagnosis before treatment. Computed tomography–guided spinal biopsy plays a major role and hence we would like to determine its utility in current clinical practice. Purpose The purpose of this study is to determine the percentage of confirmatory positives of CT-guided spinal biopsy in patients who were clinicoradiologically diagnosed with infectious spondylitis. Material and Methods A retrospective analysis of patients who underwent CT-guided biopsy for suspected infectious spondylodiscitis from 2017 to 2021 in a tertiary medical center was done. The data were filtered and obtained from the electronic database of the institution. Results In all, 259 patients underwent CT-guided biopsy of the spine. The procedure provided confirmatory results in 149 (57.5%) biospecimens. Histopathology examination was confirmatory in 95 (36.6%) of the 241 biospecimens sent. The Mycobacteria Growth Indicator Tube (MGIT) was confirmatory in 51 (19.9%) of the 250 biospecimens sent and drug resistance was seen in 6/51 (11.7%) biospecimens. Xpert TB provided confirmatory results in 72 (27.8%) of the 254 biospecimens sent and rifampicin resistance was seen in 16/72 (22.2%) biospecimens. Bacterial culture was confirmatory in 29 (11.2%) of the 250 biospecimens sent. The complication documented in this study was 0.3%. Conclusion CT-guided spinal biopsy for suspected vertebral osteomyelitis is a safe and effective minimally invasive procedure. It demonstrates a positive yield in more than half of the patients. Knowing the outcome, the patients can be appropriately counseled prior to the procedure. CT-guided biopsy results were affected by prior administration of ATT (antitubercular therapy) in suspected tuberculous spondylitis patients.

Surgical procedures with spinal instrumentation constitute a prevalent and occasionally highly indicated treatment modality in patients with pyogenic spondylodiscitis (PSD). However, surgical therapy might be associated with the need of prolonged postoperative intensive care medicine which in turn might impair intended operative benefit. Therefore, we analyzed prolonged mechanical ventilation (PMV) as an indicator variable for such intensive care treatment with regard to potential correlations with mortality in this vulnerable patient cohort. Between 2012 and 2018, 177 consecutive patients received stabilization surgery for PSD at the authors’ neurosurgical department. PMV was defined as postoperative mechanical ventilation of more than 24 h. A multivariable analysis was performed to identify independent predictors for 30-day mortality. Twenty-three out of 177 patients (13%) with PSD suffered from postoperative PMV. Thirty-day mortality rate was 5%. Multivariable analysis identified “spinal empyema” (p = 0.02, odds ratio (OR) 6.2, 95% confidence interval (CI) 1.3–30.2), “Charlson comorbidity index (CCI) > 2” (p = 0.04, OR 4.0, 95% CI 1.0–15.5), “early postoperative complications (PSIs)” (p = 0.001, OR 17.1, 95% CI 3.1–96.0) and “PMV > 24 hrs” (p = 0.002, OR 13.0, 95% CI 2.7–63.8) as significant and independent predictors for early postoperative mortality. The present study indicates PMV to significantly correlate to elevated early postoperative mortality rates following stabilization surgery for PSD. These results might entail further scientific efforts to investigate PMV as a so far underestimated negative prognostic factor in the surgical treatment of PSD. [ABSTRACT FROM AUTHOR]

Abstract Background Here, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention. Case presentation A 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient’s right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications. Conclusions Intercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

ABSTRACT: Imaging plays an important role in the diagnosis of spinal infections. Early diagnosis is paramount in the treatment of spinal infections and leads to improved outcomes. This article reviews the imaging and relevant clinical details of infections of the spine: pyogenic spondylodiscitis, tuberculous spondylodiscitis, septic facet arthritis, epidural abscess, and subdural abscess. Though radiographs can reveal subtle changes with infections, advanced imaging modalities have increased sensitivity to aid in early diagnosis. Magnetic resonance imaging (MRI) is emphasized given it is generally the most sensitive and specific advanced imaging modality. However, nuclear medicine imaging and computer tomography (CT) play a role diagnosis in cases where MRI is not available or contra-indicated. Additionally, CT is also important for image-guided biopsy to guide antimicrobial treatment.

Background Infectious spondylodiscitis is a debilitating condition and evidence-based medicine dictates confirming the diagnosis before treatment. Computed tomography–guided spinal biopsy plays a major role and hence we would like to determine its utility in current clinical practice. Purpose The purpose of this study is to determine the percentage of confirmatory positives of CT-guided spinal biopsy in patients who were clinicoradiologically diagnosed with infectious spondylitis. Material and Methods A retrospective analysis of patients who underwent CT-guided biopsy for suspected infectious spondylodiscitis from 2017 to 2021 in a tertiary medical center was done. The data were filtered and obtained from the electronic database of the institution. Results In all, 259 patients underwent CT-guided biopsy of the spine. The procedure provided confirmatory results in 149 (57.5%) biospecimens. Histopathology examination was confirmatory in 95 (36.6%) of the 241 biospecimens sent. The Mycobacteria Growth Indicator Tube (MGIT) was confirmatory in 51 (19.9%) of the 250 biospecimens sent and drug resistance was seen in 6/51 (11.7%) biospecimens. Xpert TB provided confirmatory results in 72 (27.8%) of the 254 biospecimens sent and rifampicin resistance was seen in 16/72 (22.2%) biospecimens. Bacterial culture was confirmatory in 29 (11.2%) of the 250 biospecimens sent. The complication documented in this study was 0.3%. Conclusion CT-guided spinal biopsy for suspected vertebral osteomyelitis is a safe and effective minimally invasive procedure. It demonstrates a positive yield in more than half of the patients. Knowing the outcome, the patients can be appropriately counseled prior to the procedure. CT-guided biopsy results were affected by prior administration of ATT (antitubercular therapy) in suspected tuberculous spondylitis patients. [ABSTRACT FROM AUTHOR]

Abstract Study design Retrospective single center cohort study. Purpose Spinal instrumentation in combination with antibiotic therapy is a treatment option for acute or chronic pyogenic spondylodiscitis (PSD). This study compares the early fusion outcome for multi-level and single-level PSD after urgent surgical treatment with interbody fusion in combination with fixation. Methods This is a retrospective cohort study. Over a 10 year period at a single institution, all surgically treated patients received surgical debridement, fusion und fixation of the spine to treat PSD. Multi-level cases were either adjacent to each other on the spine or distant. Fusion rates were assessed at 3 and 12 months after surgery. We analyzed demographic data, ASA status, duration of surgery, location and length of spine affected, Charlson comorbidity index (CCI), and early complications. Results A total of 172 patients were included. Of these, 114 patients suffered from single-level and 58 from multi-level PSD. The most frequent location was the lumbar spine (54.0%) followed by the thoracic spine (18.0%). The PSD was adjacent in 19.0% and distant in 81.0% of multi-level cases. Fusion rates at the 3 month follow-up did not differ among the multi-level group (p = 0.27 for both adjacent and distant sites). In the single-level group, sufficient fusion was achieved in 70.2% of cases. Pathogen identification was possible 58.5% of the time. Conclusions Surgical treatment of multi-level PSD is a safe option. Our study demonstrates that there was no significant difference in early fusion outcomes between single-level and multi-level PSD, whether adjacent or distant.

Background: Here, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention. Case presentation: A 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient's right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications. Conclusions: Intercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication. [ABSTRACT FROM AUTHOR]

Objective: Pyogenic spondylodiscitis is a severe medical condition, often requiring surgical intervention. Numerous risk factors are known, such as obesity, neurological impairment and old age. In-hospital mortality remains high, therefore other factors may be contributing to the increased mortality. To evaluate kidney function as a risk factor for increased morbidity of pyogenic spondylodiscitis, the glomerular filtration rate (GFR) was correlated with the patients' clinical course. Materials and methods: We retrospectively reviewed the cases of 366 patients and 255 were included for analysis. Clinical, laboratory and surgical data were recorded with a minimum follow-up of three months. For clinical outcome measurement, mortality, length of stay and perioperative complications were analysed. Results: The study included 255 patients (173 men, 82 women; mean age 66.3 years). Patients with a GFR < 59 mL/min spent an average of 5 days longer in the hospital than those with a GFR ≥ 60 mL/min (p = 0.071). The mortality rate increased significantly with a decrease in GFR: A GFR of 30–59 mL/min had a mortality rate of 17.6%, whereas a GFR of < 29 mL/min had one of 30.4% (p = 0.003). Patients with impaired GFR showed an increased rate of postoperative complications (OR 4.7 p = 0.002) and higher rate of intensive care unit (ICU) stay (OR 8.7 p = < 0.001). Discussion: Preoperative GFR values showed a significant correlation with in-hospital mortality in patients with spondylodiscitis, when graded according to the KDIGO stages. Furthermore, a GFR of < 29 ml/mL contributes to a longer ICU stay, postoperative complications and a longer total hospital stay. Therefore, the preoperative GFR could be a marker of kidney function and as a valuable predictive risk factor regarding the clinical in-hospital course of patients suffering from pyogenic spondylodiscitis. [ABSTRACT FROM AUTHOR]

Purpose: To determine the efficacy and poor prognostic factors of posterolateral full-endoscopic debridement and irrigation (PEDI) surgery for thoraco-lumbar pyogenic spondylodiscitis. Methods: We included 64 patients (46 men, 18 women; average age: 63.7 years) with thoracic/lumbar pyogenic spondylodiscitis who had undergone PEDI treatment and were followed up for more than 2 years. Clinical outcomes after PEDI surgery were retrospectively investigated to analyze the incidence and risk factors for prolonged and recurrent infection. Results: Of 64 patients, 53 (82.8%) were cured of infection after PEDI surgery, and nine (17.2%) had prolonged or recurrent infection. Multivariate analysis demonstrated that significant risk factors for poor prognosis included a large intervertebral abscess cavity (P = 0.02) and multilevel intervertebral infections (P < 0.05). Conclusion: PEDI treatment is an effective, minimally invasive procedure for pyogenic spondylodiscitis. However, a large intervertebral abscess space could cause instability at the infected spinal column, leading to prolonged or recurrent infection after PEDI. In cases with a large abscess cavity with or without vertebral bone destruction, endoscopic drainage alone may have a poor prognosis, and spinal fixation surgery could be considered. [ABSTRACT FROM AUTHOR]

Study design: Retrospective single center cohort study. Purpose: Spinal instrumentation in combination with antibiotic therapy is a treatment option for acute or chronic pyogenic spondylodiscitis (PSD). This study compares the early fusion outcome for multi-level and single-level PSD after urgent surgical treatment with interbody fusion in combination with fixation. Methods: This is a retrospective cohort study. Over a 10 year period at a single institution, all surgically treated patients received surgical debridement, fusion und fixation of the spine to treat PSD. Multi-level cases were either adjacent to each other on the spine or distant. Fusion rates were assessed at 3 and 12 months after surgery. We analyzed demographic data, ASA status, duration of surgery, location and length of spine affected, Charlson comorbidity index (CCI), and early complications. Results: A total of 172 patients were included. Of these, 114 patients suffered from single-level and 58 from multi-level PSD. The most frequent location was the lumbar spine (54.0%) followed by the thoracic spine (18.0%). The PSD was adjacent in 19.0% and distant in 81.0% of multi-level cases. Fusion rates at the 3 month follow-up did not differ among the multi-level group (p = 0.27 for both adjacent and distant sites). In the single-level group, sufficient fusion was achieved in 70.2% of cases. Pathogen identification was possible 58.5% of the time. Conclusions: Surgical treatment of multi-level PSD is a safe option. Our study demonstrates that there was no significant difference in early fusion outcomes between single-level and multi-level PSD, whether adjacent or distant. [ABSTRACT FROM AUTHOR]

Skipped multifocal pyogenic spondylodiscitis is a rare presentation of spinal infection. In our institution, we used the single posterior approach for circumferential debridement and anterior reconstruction with fibular allograft for treatment. This study aimed to ascertain the viability and reliability of this technique for these difficult cases. Nine patients with skipped pyogenic spondylodiscitis who received our treatment method from January 2012 to December 2019 were enrolled in this study. Visual analog scale scores, causative agents, laboratory data, comorbidities, and complications were recorded. The patients' clinical conditions were evaluated based on modified Brodsky's criteria, visual analogue scale, and Oswestry Disability Index. All the patients achieved infection eradication without repeat surgical treatment. The average visual analog scale score was 8.4 (range, 8–9) before operation, which decreased to 1.9 (range, 1–3) 1 year after the surgery. No patient experienced severe complications such as neurologic deterioration or fixation failure. All patients achieved a good or excellent outcome based on modified Brodsky's criteria. The Oswestry Disability Index improved from 80.4 (range, 70–86) preoperatively to 25.1 (range, 20–32) 1 year after the surgery. In our case series, good clinical outcomes and high successful rates could be achieved through the single-stage posterior-only approach. This could be considered an alternative method to manage patients with skipped pyogenic spondylodiscitis. [ABSTRACT FROM AUTHOR]

Background: Citrobacter species being a gram-negative, facultatively anaerobic bacteria affects extremes of age groups. Case report: We report a case of 27-yearold male with no associated comorbidities diagnosed with lumbar spondylodiscitis caused by C.koseri infection. He was managed conservatively and treated successfully with appropriate antibiotics. Conclusion: Spondylodiscitis due to C.koseri spondylodiscitis can occur in young healthy adults. Early diagnosis by blood or tissue culture & prompt medical treatment is essential for a good outcome.

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.

Background Context: Spondylodiscitis management presents significant clinical challenges, particularly in critically ill patients, where the risks and benefits of surgical intervention must be carefully balanced. The optimal timing of surgery in this context remains a subject of debate., Purpose: This study aims to evaluate the effectiveness of early surgery versus delayed surgery or conservative management in critically ill patients with de novo pyogenic spondylodiscitis., Study Design/setting: This is an international, multicenter retrospective cohort study involving 24 centers, primarily in Europe., Patient Sample: The study included 192 critically ill patients (65.63% male) with a median age of 69 years, all severely affected by pyogenic spondylodiscitis characterized by an initial CRP level >200 mg/l or the presence of two out of four Systemic Inflammatory Response Syndrome criteria upon admission., Outcome Measures: The primary outcome was 30-day mortality. Secondary outcomes included length of ICU stay, length of hospital stay, and relapse rates of spondylodiscitis., Methods: Patients were divided into three groups: early surgery (within three days of admission), delayed surgery (after three days of admission), and conservative therapy. Propensity score matching and multivariate regression analyses were performed to adjust for baseline differences and assess the impact of treatment modalities on mortality and other clinical outcomes., Results: Delayed surgery was associated with significantly lower 30-day mortality (4.05%) compared to early surgery (27.85%) and conservative therapy (27.78%) (p<0.001). Delayed surgery also resulted in shorter hospital stays (42.76 days) compared to conservative therapy (55.53 days) and early surgery (26.33 days) (p<0.001), and shorter ICU stays (4.52 days) compared to conservative therapy (16.48 days) and early surgery (7.92 days) (p<0.001). The optimal window for surgery, minimizing mortality, was identified as ten to fourteen days post-admission (p=0.02). Risk factors for increased mortality included age (p<0.05), multiple organ failure (p<0.05), and vertebral body destruction (p<0.05), whereas delayed surgery (p<0.05) and the presence of an epidural abscess were associated with reduced mortality (p<0.05)., Conclusions: Delayed surgery, optimally between 10 to 14 days post-admission, was associated with lower mortality in critically ill spondylodiscitis patients. These findings highlight the potential benefits of considering surgical timing to improve patient outcomes., Competing Interests: Declaration of competing interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024. Published by Elsevier Inc.)

The anterior approach is one of the widely used surgical treatments for lumbar spondylodiscitis, but it has the disadvantages of large trauma and a high incidence of complications. Our experiences suggested that the laparoscopic retroperitoneal approach could be effective to overcome those disadvantages of the anterior approach. Herein, we report two cases of successfully treated lumbar pyogenic spondylodiscitis using a robot-assisted laparoscopic retroperitoneal approach. The technique utilizes a robot that allows a laparoscopic retroperitoneal approach while offering excellent high-definition images of three-dimensional vision. After the operation, both patients achieved good formation and fusion of the vertebrae. Preliminary evidence suggests that the robot-assisted laparoscopic retroperitoneal approach may be feasible for the treatment of lumbar 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: In patients with pyogenic spondylodiscitis, surgery is considered the treatment of choice to conduct proper debridement, stabilise the spine and avoid extended bed rest, which in turn is a risk factor for complications such as deep vein thrombosis and pulmonary embolism. Methods: We conducted a retrospective clinical study with analysis of a group of 99 patients who had undergone treatment for pyogenic discitis at our institution between June 2012 and August 2017. Included parameters were age, sex, disease pattern, the presence of deep vein thrombosis, resuscitation, in-hospital mortality, present anticoagulation, preexisting comorbidities, tobacco abuse, body mass index, microbiological germ detection and laboratory results. Results: Among the analysed cohort, 12% of the treated patients for pyogenic spondylodiscitis suffered from a radiologically confirmed pulmonary embolism. Coronary heart disease (p < 0.01), female sex (p < 0.01), anticoagulation at admission (p < 0.01) and non-O blood type (p < 0.001) were associated with development of pulmonary embolism. Pulmonary embolism was significantly associated with resuscitation (p < 0.005) and deep vein thrombosis (p < 0.001). Neurosurgery was not associated with increased risk for pulmonary embolism compared to conservative-treated patients (p > 0.05). Conclusion: Surgery for pyogenic spondylodiscitis was not associated with an elevated risk of pulmonary embolism in our analysis. However, we describe several risk factors for pulmonary embolism in this vulnerable cohort. Prospective studies are necessary to improve prevention and postoperative management in patients with pyogenic spondylodiscitis. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract Background Pyogenic spondylodiscitis (PSD) is challenging to the orthopedist with regards to diagnosis and treatment. The present study was designed to assess and suggest the most indicative diagnostic method and evaluate the effect of surgery comprising of debridement, instrumentation and fusion in treating PSD. Methods Seventy-six patients with PSD who underwent surgical intervention were retrospectively enrolled. Their medical documents, corrections of spinal alignment and improvements in neurological function were assessed. Surgical approaches were compared in lumbar surgeries regarding the improvements in lordotic angle and neurological function. Results Elevated c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were found in 77.6 and 71.1% patients respectively. Infectious lesions were found at lumbar (85.5%), cervical (10.5%) and thoracic (3.9%), ascertained with contrast-enhanced MRI. For lumbar patients, surgery was performed through the anterior (26.2%), posterior (49.2%) or combined approach (24.6%), and differences in improvement of lordosis and neurological function between each approach were insignificant. The pathogen was identified in 22.4% of the patients. Postoperative antibiotic therapy was managed against the result of susceptibility test, or empirically given to patients with negative cultures. All antibiotic therapy was initiated intravenously for 4–6 weeks and orally for 6 weeks. Conclusion Elevated CRP and/or ESR, with focal hyper-intensity on contrast-enhanced MRI are suggestive of possible PSD. Surgical intervention comprising of debridement, short-segment instrumentation and fusion that early applied to the PSD patients followed by postoperative antibiotic therapy have demonstrated preferable outcomes, but require further study. The translational potential of this article This article advocates early surgery to enable prompt diagnosis and treatment of PSD, and thus guarantee favorable outcomes for patients, as is shown in our study. In addition, different surgical approaches to the lesions were compared and discussed in this manuscript, but no differences in outcome between approaches were found. This suggests that thorough debridement should be prioritized over selection of surgical approach. In summary, this article has large translational potential to be applied clinically.

Abstract Background Due to the unspecific symptoms of spondylodiscitis (SpD), an early radiological examination is necessary. However, controversially discussed is the need for 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.

Purpose: Pyogenic spondylodiscitis is a relatively rare spinal disease; non-specific spondylodiscitis (NSS) cases are increasing. This study aims to identify if changes of inflammatory markers under antibiotic therapy can be used to determine which NSS patients can benefit from surgical indication earlier than others. Methods: Two groups of patients with NSS were examined. Group A underwent surgery, while Group B was treated conservatively. Group B was also subdivided in patients undergoing antibiotic therapy for > 6 weeks (B1) and < 6 weeks (B2). Groups were compared for age, gender, BMI, blood levels of ESR and CRP and VAS scale. Results: There were no differences (P = 0.06) in reduction in ESR at 4 weeks between two main groups. A reduction in CRP, with < 2.7 mg/dl at 4 weeks, was observed in Group A (P = 0.01). Comparing Group B1 to B2, a reduction (P = 0.0001) in VAS, ESR and CRP at 4 weeks was observed in Group B2. It was possible to isolate the pathogen in 52.8% of Group B, without any differences on VAS, ESR and CRP values and on length of the antibiotic therapy. Conclusions: The surgical treatment should be considered for patients who, after 4 weeks of conservative therapy, do not show a reduction in the ESR < 50 mm/h and of the CRP < 2.7 g/dl. The comparison between groups underwent surgically and those treated conservatively showed a reduction in the CRP at 4 weeks and better VAS for pain at 3 months in Group A. [ABSTRACT FROM AUTHOR]

Abstract Background Pyogenic spondylodiscitis is an extremely rare complication of esophagectomy for esophageal cancer. Case presentation A 70-year-old Japanese man, with a previous medical history of type 2 diabetes mellitus, coronary artery disease, and laryngeal cancer, received neoadjuvant chemotherapy and underwent thoracoscopic esophagectomy with gastric tube reconstruction for advanced esophageal cancer. Cervical esophagogastrostomy with circular-stapled end-to-side anastomosis was performed. However, partial necrosis in the gastric tube developed to form refractory anastomotic fistula. Two months after the initial surgery, debridement and free jejunal transfer reconstruction with the pectoralis major muscle flap were performed. Although the postoperative course of the second surgery was uneventful, the patient complained of severe lower back pain and fever. The patient was diagnosed with pyogenic spondylodiscitis according to the results of the magnetic resonance imaging. Enterobacter cloacae were isolated from the arterial blood culture. Sensitive antibiotics were administered continuously, and the patient required to use a lumbar corset for 2 months. Subsequently, his physiological signs and symptoms had completely disappeared. Conclusion To the best of our knowledge, this case study is the first study that reported pyogenic spondylodiscitis of the lumbar spine, a complication of cervical anastomotic fistula after surgery for advanced esophageal cancer.

Purpose: In the surgical treatment of pyogenic lumbar spondylodiscitis, screw insertion at the affected vertebra has been avoided because of biofilm formation, and the risk of infection recurrence. The authors analyzed the success rate of infection treatment while minimizing the number of instrumented segments by inserting pedicle screws into the affected vertebrae. Therefore, this study examined the usefulness of this technique. Materials and Methods: From January 2000 to June 2018, among patients with pyogenic lumbar spondylodiscitis treated surgically, group A consisted of patients with pedicle screws inserted directly at the affected vertebrae (28 cases), and group B underwent fusion by inserting screws at the adjacent normal vertebrae due to bone destruction of the affected vertebral pedicle (20 cases). The classified clinical results were analyzed retrospectively. All patients were treated via the posterior-only approach, so the affected disc and sequestrum were removed. Posterior interbody fusion was performed with an autogenous strut bone graft, and the segments were then stabilized with pedicle screw systems. The hospitalization period, operation time, amount of blood loss, EQ-5D index, duration of intravenous antibiotics, and the clinical and radiological results were analyzed. Results: In group A, the number of instrumented segments, operation time, blood loss, and EQ-5D index at one month postoperatively showed significant improvement compared to group B. There were no significant differences in the duration of antibiotic use, hospitalization, radiological bone union time, sagittal angle correction rate, and recurrence rate. Conclusion: Minimal segmental fixation, in which pedicle screws were inserted directly into the affected vertebrae through the posterior approach, reduced the surgery time and blood loss, preserved the lumbar motion by minimizing fixed segments and showed rapid recovery without spreading or recurrence of infection. Therefore, this procedure recommended for the surgical treatment of lumbar pyogenic spondyodiscitis. [ABSTRACT FROM AUTHOR]

Pyogenic spondylodiscitis (PSD) is a complex disorder that often required postoperative imaging. Carbon-fiber–reinforced polyether ether ketone (CFRP) is radiolucent and offers an optimal assessability of anatomic structures. A retrospective file review of patients who were operated on for PSD using CFRP implants was performed to assess the clinical outcome, implant-associated complications, and revision surgery. A minimum follow-up of 3 months was required for evaluation of clinical and radiographic data, which included computed tomography and magnetic resonance imaging (MRI) assessment, to determine implant stability and assessability of soft tissue and nerve structures using a grading system. Eighty-one consecutive patients with a mean of 69.5 years were identified. Debridement and stabilization were performed in 8 cervical, 17 thoracic, and 57 lumbar procedures; 72 interbody fusion procedures using cages were performed. Intraoperatively, no implant-associated complication was noted. The mean follow-up was 7 months, at which 52 patients attended. Improved mobility and reduced pain levels were reported by 87%, and MRI assessability was graded ideal. Residual sign of infection was seen in 5 cases, which influenced antibiotic therapy. Asymptomatic radiolucent zones were identified in 13 patients (16%) and screw loosening in 2 (2.4%). In 1 patient, the pedicle screw tip broke and remained within the vertebral body. A repeated procedure because of progressive vertebral body destruction, implant loosening, or subsidence was performed in 5 patients (6.1%). The surgical treatment of PSD using CFRP is safe. The repeat procedure rate as a result of implant loosening is 6.1%. Minimal artifacts offer ideal assessability of soft tissue structures on an MRI. [ABSTRACT FROM AUTHOR]

We report a rare case of Campylobacter fetus meningitis and pyogenic spondylodiscitis in a healthy young woman. A 35-year-old woman without significant medical history presented with fever, headache, and low back pain. C. fetus was detected from the blood culture. Cerebrospinal fluid analysis showed bacterial meningitis 2 days after onset. Although initial magnetic resonance imaging (MRI) did not reveal abnormal findings, repeated MRI showed a low-signal-intensity lesion on T1-weighted image (T1WI) and a high-signal-intensity lesion on T2WI between the L5 and S1 vertebral bodies 11 days after onset. The mode of infection was considered to be the consumption of raw chicken meat. After antibiotic treatment with 12 g/day ampicillin following 6 g/day meropenem, she was discharged 51 days after onset. As the inflammatory signs on MRI improved, oral antibiotic therapy was discontinued 85 days after onset. Although the initial MRI showed no abnormal findings, repeat MRI should be performed for patients who have persistent low back pain and fever.

Study Design Retrospective case series. Purpose The aim of this study was to analyze functional and radiological outcomes in patients with culture-negative pyogenic vertebral osteomyelitis (PVO). Overview of Literature There were only few literature available for these group of patients. Methods Patients with biopsy-positive but culture-negative PVO were included. We analyzed records for data on demography, comorbidities, coexisting infections, neurological status, prior antibiotic therapy, pre- and postoperative erythrocyte sedimentation rate, C-reactive protein levels, and Oswestry Disability Index, and Japanese Orthopedics Association scores. Results Sixty-one patients were included, of which data of 45 patients were available for follow-up. The patients were predominantly males (71%), with a mean age of 53.2 years. Seventy-seven percent patients had comorbidities. Echocardiography, blood culture, and urine culture were performed on 8%, 24%, and 18% of patients, respectively. Thirty-one percent patients had neurological deficits. Computed tomography-guided biopsy was performed on 67% patients. Fifty-two percent patients were treated surgically, and 48% were treated non-surgically. Nineteen percent patients were treated according to the results of cultures from other foci, and the rest were treated empirically. For the initial 2 weeks, all patients were treated with intravenous antibiotics empirically or based on culture from other foci. This treatment was followed by 10 weeks of oral cloxacillin/cephalexin for gram-positive organisms or ciprofloxacin for gram-negative organisms. The mean follow-up time was 18 months (range, 12–120 months). All patients had improvement in Japanese Orthopedics Association, Oswestry Disability Index, and Visual Analog Scale scores (p

Corynebacterium jeikeium normally presents on human skin, and it is often judged as contamination when it is cultured from blood. C. jeikeium can cause infective endocarditis, especially, that associated with cardiac surgery and prosthetic valvular endocarditis. A 66-year-old Japanese male patient was diagnosed with C. jeikeium -induced infective endocarditis (IE) and perivalvular abscess after a coronary artery bypass grafting and aortic valve replacement with bioprosthesis; pyogenic spondylodiscitis was also observed. Patch repair for aortic valve annulus and re-Bentall procedure with bioprosthesis was performed for IE and perivalvular abscess. The causative bacterium was confirmed as C. jeikeium on 16S ribosomal RNA sequencing of surgical sample and positive blood culture. The patient underwent six weeks of intravenous antibacterial treatment with vancomycin and an additional two weeks of oral treatment with linezolid, following which, his condition improved. Corynebacterium jeikeium can cause infective endocarditis and perivalvular abscess, which is a more severe condition than IE. 16S ribosomal RNA sequencing is useful in diagnosing bacterial species that can cause contamination, such as Corynebacterium spp. [ABSTRACT FROM AUTHOR]

Purpose. To demonstrate options and alternative for drainage of inaccessible presacral abscess by the example of a rare clinical case of pyogenic spondylodiscitis, transsacraly drained under a combination of two interventional techniques – CT-guided bone biopsy and abscess drainage. Materials and methods. A 55-year-old patient with history of recurrent paravertebral abscesses previously treated with antibiotic therapy was referred to our institution experiencing lower back pain and weakness in both lower extremities. Computed tomography revealed pyogenic spondylodiscitis along with left facet joint destruction and presacral abscess located in ventral sacral surface. Due to inaccessible abscess location, it was decided to perform CT-guided percutaneous transsacral abscess drainage. An 8G bone marrow biopsy needle was used to penetrate the sacrum and create a path for drainage catheter placement. Using the Seldinger technique 8 Fr drainage catheter was inserted into abscess cavity. Results. Neither early nor late procedure-related complications occurred. Sixteen days after drainage procedure, the catheter was withdrawn as patient’s condition improved and the outflow of pus had reduced considerably. Conclusions. Despite being rarely used, CT fluoroscopy-guided transsacral drainage approach is considered to be minimally invasive and in some cases the only viable option for drainage of pyogenic spondilodiscitis of the lumbosacral junction.

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: Pyogenic spondylodiscitis (PSD) is challenging to the orthopedist with regards to diagnosis and treatment. The present study was designed to assess and suggest the most indicative diagnostic method and evaluate the effect of surgery comprising of debridement, instrumentation and fusion in treating PSD.Methods: Seventy-six patients with PSD who underwent surgical intervention were retrospectively enrolled. Their medical documents, corrections of spinal alignment and improvements in neurological function were assessed. Surgical approaches were compared in lumbar surgeries regarding the improvements in lordotic angle and neurological function.Results: Elevated c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were found in 77.6 and 71.1% patients respectively. Infectious lesions were found at lumbar (85.5%), cervical (10.5%) and thoracic (3.9%), ascertained with contrast-enhanced MRI. For lumbar patients, surgery was performed through the anterior (26.2%), posterior (49.2%) or combined approach (24.6%), and differences in improvement of lordosis and neurological function between each approach were insignificant. The pathogen was identified in 22.4% of the patients. Postoperative antibiotic therapy was managed against the result of susceptibility test, or empirically given to patients with negative cultures. All antibiotic therapy was initiated intravenously for 4-6 weeks and orally for 6 weeks.Conclusion: Elevated CRP and/or ESR, with focal hyper-intensity on contrast-enhanced MRI are suggestive of possible PSD. Surgical intervention comprising of debridement, short-segment instrumentation and fusion that early applied to the PSD patients followed by postoperative antibiotic therapy have demonstrated preferable outcomes, but require further study.the Translational Potential Of This Article: This article advocates early surgery to enable prompt diagnosis and treatment of PSD, and thus guarantee favorable outcomes for patients, as is shown in our study. In addition, different surgical approaches to the lesions were compared and discussed in this manuscript, but no differences in outcome between approaches were found. This suggests that thorough debridement should be prioritized over selection of surgical approach. In summary, this article has large translational potential to be applied clinically. [ABSTRACT FROM AUTHOR]

Background: Due to the unspecific symptoms of spondylodiscitis (SpD), an early radiological examination is necessary. However, controversially discussed is the need for 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. [ABSTRACT FROM AUTHOR]

Objective: The incidence of spondylodiscitis is rising across Europe, but the ideal treatment approach remains controversial. The choice between conservative and surgical therapies is ambiguous due to a lack of consensus. This European survey aimed to explore prevailing treatment paradigms for primary spondylodiscitis., Methods: Spine neurosurgeons were invited through the European Association of Neurosurgical Societies Spine Section's mailing list to participate in an online survey featuring 7 spondylodiscitis case vignettes. Along with general management queries, specific patient treatment questions were posed. Data analysis was performed using R software (version 4.0.4). The index of qualitative variation (IQV) was calculated to quantify the variability in responses., Results: A total of 130 responses were collected, comprising 86.9% board-certified neurosurgeons and 13.1% neurosurgeons in training, with an average of 11 years of practice. Most respondents performed 50-100 spine surgeries annually, with 66.7% specializing in spine surgery. An epidural empyema causing pronounced neurological deficits influenced 95.4% toward a surgical intervention, and mild neurological deficits and challenges in pathogen identification prompted 72.3% and 80%, respectively, to consider a surgical approach. Vertebral body destruction and spinal deformity directed 60% and 66.2%, respectively, toward surgery, whereas advanced age and comorbidities had a much smaller impact-5.4% and 9.2%, respectively. Clinical vignettes highlighted a predominant preference for conservative treatment in specific cases, with statistical significance (p < 0.05). The IQV values evaluated for each question ranged from 0.88 to 0.99, indicating low agreement across all questions among respondents. When examining the average IQV by country, intercountry variations in IQV were substantial, as illustrated by the diverse range of overall mean IQV values (0.15-0.85)., Conclusions: The findings reveal a significant variability in the treatment of spondylodiscitis among European neurosurgeons, with most neurosurgeons opting for conservative treatment. These diverse strategies, both between and within countries, highlight an imperative for evidence-backed guidelines and consensus statements for this grave condition.

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.

Abstract 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.

Abstract Background The primary management of pyogenic spondylodiscitis is conservative. Once the causative organism has been identified, by blood culture or biopsy, administration of appropriate intravenous antibiotics is started. Occasionally patients do not respond to antibiotics and surgical irrigation and debridement is needed. The treatment of these cases is challenging and controversial. Furthermore, many affected patients have significant comorbidities often precluding more extensive surgical intervention. The aim of this study is to describe early results of a novel, minimally invasive percutaneous technique for disc irrigation and debridement in pyogenic spondylodiscitis. Materials and methods A series of 10 consecutive patients diagnosed with pyogenic spondylodiscitis received percutaneous disc irrigation and debridement. The procedure was performed by inserting two Jamshidi needles percutaneously into the disc space. Indications for surgery were poor response to antibiotic therapy (8 patients) and the need for more extensive biopsy (2 patients). Pre- and postoperative white blood cell count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Oswestry disability index (ODI), and visual analogue score (VAS) for back pain were collected. Minimum follow-up was 18 months, with regular interval assessments. Results There were 7 males and 3 females with a mean age of 67 years. The mean WBC before surgery was 14.63 × 109/L (10.9–26.4) and dropped to 7.48 × 109/L (5.6–9.8) after surgery. The mean preoperative CRP was 188 mg/L (111–250) and decreased to 13.83 mg/L (5–21) after surgery. Similar improvements were seen with ESR. All patients reported significant improvements in ODI and VAS scores after surgery. The average hospital stay after surgery was 8.17 days. All patients had resolution of the infection, and there were no complications associated with the procedure. Conclusions Our study confirms the feasibility and safety of our percutaneous technique for irrigation and debridement of pyogenic spondylodiscitis. Percutaneous irrigation and suction offers a truly minimally invasive option for managing recalcitrant spondylodiscitis or for diagnostic purposes. The approach used is very similar to discography and can be easily adapted to different hospital settings. Level of Evidence Level III

George Kuo,1 Wei-Chiao Sun,1 Yueh-An Lu,1 Chao-Yu Chen,1 Huang-Kai Kao,2 YuJr Lin,3 Yung-Chang Chen,4 Cheng-Chieh Hung,1 Ya-Chung Tian,1 Hsiang-Hao Hsu1 1Department of Nephrology, Kidney Research Center, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan; 2Department of Plastic and Reconstructive Surgery, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan; 3Center for Big Data Analytics and Statistics, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan; 4Department of Internal Medicine, Division of Nephrology, College of Medicine, Keelung Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan Purpose: Infectious spondylodiscitis is a serious disease that can lead to permanent neurological deficit. Because there were only a few case reports or series featuring infectious spondylodiscitis in chronic dialysis patients, we investigated the epidemiology and outcome in the chronic dialysis patients versus general population.Materials and methods: We retrospectively identified chronic dialysis patients admitted for infectious spondylodiscitis between January 2002 and December 2015. A total of 105 chronic dialysis patients were included, and we performed a 1:2 case–control match on propensity score in non-dialysis patients with infectious spondylodiscitis. The demographic features, clinical manifestation, infection focus, and disease outcome were recorded.Results: A total of 302 patients entered the final analysis. Chronic dialysis patients less frequently had fever (34.3%), and in the majority, bacterial entry was through dialysis vascular access (30.5%). Methicillin-resistant Staphylococcus aureus (MRSA) comprised the majority of causative pathogen. The chronic dialysis group had longer hospital stay, higher in-hospital mortality, and higher 1-year mortality. The odds ratio of in-hospital mortality was 2.20 compared with the non-dialysis group.Conclusions: The study highlighted poorer outcome and high frequency of resistant Staphylococcus of infectious spondylodiscitis in chronic dialysis patients. Therefore, high vigilance, prompt recognition, and empiric coverage of MRSA will be important in the management of infectious spondylodiscitis in chronic dialysis patients. Keywords: end stage renal disease, pyogenic spondylodiscitis, infectious spondylodiscitis, methicillin-resistant Staphylococcus aureus, mortality

Objective: The aim of this study was to determine an effective treatment by antibiotic for positive culture (culture+ve) pyogenic spondylodiscitis compared to a negative culture (culture-ve) by assessment of laboratory outcomes, Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP). The secondary objective is to determine incidence of pathogen micro-organisms of pyogenic spondylodiscitis. Material and Method: The study design was a single-center retrospective study performed by the ICD10 computer database of the Department of Orthopedic Surgery in the Prince of Songkla University for patient diagnosed pyogenic spondylodiscitis. After exclusion was done, patients were divided into 2 groups of study. The first group was tissue ulture+ve while the second group was tissue culture-ve. Patient culture+ve were analyzed for bacterial pathogen along with antibiotic sensitivity. In culture-ve patients were analyzed for the types of antibiotic and its usage. Both of two groups was compared with the effectiveness of treatment with ESR and CRP beforehand, and after four-weeks of treatment. Results: Compared with 56 culture+ve patients, the 69 culture-ve patients were no significant difference in median difference of ESR and CRP at the time before treatment and at four-weeks, after treatment. Conclusion: Antibiotic treatment of non-identified micro-organism pyogenic spondylodiscitis can be done by using the most common incidence of micro-organism. The effectiveness of antibiotic treatment was determine by ESR and CRP beforehand, and after four-weeks of antibiotic treatment.

Background: Pyogenic spondylodiscitis is an extremely rare complication of esophagectomy for esophageal cancer. Case presentation: A 70-year-old Japanese man, with a previous medical history of type 2 diabetes mellitus, coronary artery disease, and laryngeal cancer, received neoadjuvant chemotherapy and underwent thoracoscopic esophagectomy with gastric tube reconstruction for advanced esophageal cancer. Cervical esophagogastrostomy with circular-stapled end-to-side anastomosis was performed. However, partial necrosis in the gastric tube developed to form refractory anastomotic fistula. Two months after the initial surgery, debridement and free jejunal transfer reconstruction with the pectoralis major muscle flap were performed. Although the postoperative course of the second surgery was uneventful, the patient complained of severe lower back pain and fever. The patient was diagnosed with pyogenic spondylodiscitis according to the results of the magnetic resonance imaging. Enterobacter cloacae were isolated from the arterial blood culture. Sensitive antibiotics were administered continuously, and the patient required to use a lumbar corset for 2 months. Subsequently, his physiological signs and symptoms had completely disappeared. Conclusion: To the best of our knowledge, this case study is the first study that reported pyogenic spondylodiscitis of the lumbar spine, a complication of cervical anastomotic fistula after surgery for advanced esophageal cancer. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]