Failure modes in conservative and surgical management of infectious spondylodiscitis

Abstract

Purpose and methods We reviewed the management, failure modes, and outcomes of 196 patients treated for infectious spondylodiscitis between January 1, 2000 and December 31, 2010, at the Spinal Unit, Aarhus University Hospital, Aarhus, Denmark. Patients with infectious spondylodiscitis at the site of previous spinal instrumentation, spinal metastases, and tuberculous and fungal spondylodiscitis were excluded. Results Mean age at the time of treatment was 59 (range 1-89) years. The most frequently isolated microorganism was Staphylococcus aureus. The lumbosacral spine was affected in 64 % of patients and the thoracic in 21 %. In 24 % of patients, there were neurologic compromise, four had the cauda equina syndrome and ten patients were paraplegic. Ninety-one patients were managed conservatively. Treatment failed in 12 cases, 7 patients required re-admission, 3 in-hospital deaths occurred, and 5 patients died during follow-up. Posterior debridement with pedicle screw instrumentation was performed in 75, without instrumentation in 19 cases. Seven patients underwent anterior debridement alone, and in 16 cases, anterior debridement was combined with pedicle screw instrumentation, one of which was a two-stage procedure. Re-operation took place in 12 patients during the same hospitalization and in a further 12 during follow-up. Two in-hospital deaths occurred, and five patients died during follow-up. Patients were followed for 1 year after treatment. Eight (9 %) patients treated conservatively had a mild degree of back pain, and one (1 %) patient presented with mild muscular weakness. Among surgically treated patients, 12 (10 %) had only mild neurological impairment, one foot drop, one cauda equine dysfunction, but 4 were paraplegic. Twenty-seven (23 %) complained of varying degrees of back pain. Conclusions Conservative measures are safe and effective for carefully selected patients without spondylodiscitic complications. Failure of conservative therapy requires surgery that can guarantee thorough debridement, decompression, restoration of spinal alignment, and correction of instability. Surgeons should master various techniques to achieve adequate debridement, and pedicle screw instrumentation may safely be used if needed.

Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review

“…At total of 75 patients in the current review had tuberculosis and 52 patients had a postoperative infection, which represented, respectively, 3.1 and 2.2 % of all included patients. Similarly, four included study populations consisted of 0.9-13.5 % children and adolescent patients [4,6,27,34]. Additionally 3 other studies contained patients between 16 and 18 years of age; however, the number of these patients is not described [32,35,36].…”

“…Additionally 3 other studies contained patients between 16 and 18 years of age; however, the number of these patients is not described [32,35,36]. A total number of 31 children and adolescents have described in the included studies and represent 1.3 % of the study population in this review [4,6,27,34].…”

“…Three studies retrospectively compared systemic antibiotics alone versus surgical treatment [27,34,43]. The indication for surgical treatment in the first two studies was neurologic compromise, extensive bone destruction, epidural abscess formation, failure of nonoperative treatment or intractable back pain.…”

The Michel Benoist and Robert Mulholland Yearly European Spine Journal Review: a survey of the “surgical and research” articles in the European Spine Journal, 2013

“…In discussing surgical treatment I was surprised they felt pedicle fixation should be added to an adequate anterior clearance and grafting, even in the absence of any posterior destruction. The paper by Valancius et al [33] reinforces much of the above. Of the 196 patients they treated with spondylodiscitis, 91 were treated conservatively, and 105 operatively.…”

“…This was because the authors felt that anterior surgery alone with grafting was not sufficiently stable, and operating from both the front and back with separate approaches was too invasive. Their results seem to support the views that a posterior approach alone is satisfactory, using a transforaminal lumbar interbody fusion to clear the disc, and do an interbody graft, then combined with pedicle fixation [33]. The paper by Gorensek et al [9] operated upon 23 of 108 patients, indicating that nonoperative treatment is most frequently most appropriate.…”