Object Pyogenic vertebral osteomyelitis is of special interest to neurosurgeons because it often results in acute neurological deterioration and requires a combination of adequate surgical and conservative treatment. The aim of the current study was to evaluate the strategy of a primary surgical approach to this disease. Methods A group of 24 patients with the clinical and radiological signs of acute pyogenic spondylodiscitis was prospectively followed from 1998 to 2004. Of these, 20 had underlying diseases such as diabetes mellitus, chronic alcoholism, and liver cirrhosis. The main causative organism was Staphylococcus aureus. Most infections were localized in the thoracic or lumbar spine (10 cases each); 15 infections were associated with epidural abscesses. Because of a delay in diagnosis, 13 patients presented with neurological deficits on admission. Patients with a complete or rapidly progressing neurological deficit underwent immediate surgery. In patients with minor or no deficits or in a stable neurological condition, surgery was delayed for 3 to 5 days. This group was treated with immobilization and intravenous antibiotic drugs before surgery. Surgical procedures included ventral, dorsal, and combined approaches in one- or two-stage operations. Antibiotic treatment included the use of broad-spectrum antibiotic drugs delivered intravenously for at least 10 days, followed by orally administered antibiotics for 3 months. Twenty patients were independent on follow-up review, 15 with no or minor handicaps. Severe septicemia and multiorgan failure developed in two patients, and these two died of their disease. Major complications were mainly due to long-term antibiotic therapy. Conclusions Surgical treatment is the modality of choice in patients with acute spinal osteomyelitis. It is especially indicated in patients with progressive or severe neurological deficits and spinal deformity. In experienced hands, surgery is safe and offers the advantages of spinal cord decompression, immediate mobilization, and correction of spinal deformity. The decision whether an anterior or posterior approach should be used must be made on an individual basis.

We report a case of spondylodiscitis due to Streptococcus dysgalactiae subsp. equisimilis spreading from infected leg ulcers. The route of infection could be unequivocally demonstrated by culturing identical isolates from leg wounds, blood culture and intra-surgery specimens from the spine. The present case illustrates the pathogenic potential of group G streptococci also for nondiabetic adults. Case reportIn January 2006, a 59-year-old male patient was admitted to the Department of Orthopaedics of the Rostock University Hospital with extreme lower back pain. He had been suffering from increasing back pain for about 3 months and had experienced three to four episodes of fever up to 40 u C lasting 1-2 days within the last 6 months. He had lost 40 kg of weight without intention during the previous year.Careful history taking revealed a history of coronary heart disease, a myelodysplastic syndrome with refractive anaemia, chronic recurrent pancreatitis and a seminoma (relapse-free for 14 years). The patient had also suffered from leg ulcers for about 9 months due to circulatory disturbances of both legs and a post-thrombotic syndrome after a pelvic vein thrombosis years ago.On admission, we saw a critically ill, moderately obese patient (89 kg/173 cm) who was alert and fully oriented. Body temperature was slightly elevated (37.4 u C). The blood pressure was normal at 105/60 mmHg. The heart sounds, skin aspect and nails beds as signs for endocarditis as well as results from transthoracic echocardiography were unremarkable. Arterial pulses were palpable except for the Aa. dorsalis pedis on both sides. There were leg ulcers on both legs with clinical signs of bacterial infection such as inflamed rims, pus, smear and odour (Fig. 1). The microbiological cultures from superficial swab material taken from both legs grew b-haemolytic group G streptococci (GGS; Streptococcus dysgalactiae subsp. equisimilis) and Staphylococcus aureus. Other parameters of the physical examination were unremarkable.The lower spine was sensitive to percussion. Symmetrical radicular pain was reported to reach from the rear side of the thighs to the knees concordant with dermatomes L5 being affected. The deep tendon reflexes of the legs were slowly releasable equally on both sides. Motor strength and sensory function were normal. The patient was continent.On admission, the white blood cell count was slightly elevated with 12.4610 9 cells l 21 (normal range 4-9610 9 cells l 21 ). Other infection parameters such as C-reactive protein (241 mg l 21 ; normal ,5 mg l 21 ), procalcitonin (2.42 ng ml 21 ; normal ,0.5 ng ml 21 ) and erythrocyte sedimentation rate (105 mm h 21 ) were remarkably elevated.The red blood cell count showed a normocytic anaemia with decreased values for haemoglobin (4.5 mmol l 21 ; normal range 8.6-12 mmol l 21 ) and haematocrit (23 %; normal range 40-51 %); thrombocytes were normal (334610 9 cells l 21 ). Liver enzymes were within the normal range except for an elevated alkaline phosphatase (182 U l 21 ; normal range 38-126 U l...

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