Management of Pyogenic Spinal Infection, review of literature

doi:10.1016/j.jor.2019.08.014

Journal of Orthopaedics

Volume 16, Issue 6, November–December 2019, Pages 508-512

https://doi.org/10.1016/j.jor.2019.08.014 Get rights and content

Abstract

Objective

To evaluate the available evidence for the management of Pyogenic Spinal Infection (PSI).

Methods and results

A comprehensive search for the relevant literature published between 1990 and 2018 to evaluate the management of PSI was conducted.

Nonoperative management of carefully selected patients for an adequate duration of antibiotics can result in satisfactory outcomes with low recurrence rate. When there is an indication for surgery, posterior approach, with or without debridement of infected tissue reported to be associated with good outcomes.

Conclusion

Studies with larger sample sizes and longer duration of follow up are recommended to formulate more comprehensive evidence.

Introduction

Pyogenic Spinal Infection (PSI) is a rare, serious condition, and recent literature has suggested high rates of morbidity and mortality.¹^,² PSI includes a wide spectrum of conditions, such as discitis, vertebral osteomyelitis, both discitis and vertebral osteomyelitis (spondylodiscitis), or Spinal Epidural Abscess (SEA).³^,⁴ The annual incidence of PSI ranges from 0.5 to 2.2/100,000 people, and the infection commonly tends to affect elderly or chronically ill patients.¹^,⁵ However, in the past few decades, there has been an increase in the incidence of PSI⁶ attributed to an advancing population and increased numbers of immunocompromised patients.⁷^,⁸

Staphylococcus aureus is the most common causative micro-organism identified.⁹ Others include gram positive cocci such as; Streptococcus viridans or Staphylococcus epidermis, or gram negative bacteria such as; Echerichia coli.³^,¹⁰ The most common site for spinal infection is the lumbar spine, followed by thoracic spine, cervical spine, and to a lesser extent sacral spine.⁴

Back or neck pain, which can be continuous and unremitting is the most common presentation of patients with PSI. Other symptoms include fever, chills, loss of weight, malaise or neurological symptoms.⁴ Delayed diagnosis can occur up to 3 months because of the non-specific initial symptoms, especially when pain and/or fever are the only presenting symptoms.¹¹^,¹² Literature suggests that early diagnosis of PSI allows for early commencement of treatment, more effective response and better prognosis.⁴^,¹³

PSI can be managed either by nonoperative measures, including intravenous or oral antibiotics and other supportive non-pharmacological measures, such as immobilisation/bracing or by surgical intervention.¹⁴ In general, conservative management can be considered when there is no indication for surgical intervention.¹² However, if there is any indication for surgery, or if conservative management has failed to control or eradicate the infection, then surgical intervention may be required.¹⁵

Section snippets

Method and results

A comprehensive search for the most relevant literature was performed using the following key words: spine, infection, management, surgery, posterior, spondylitis, discitis, spondylodiscitis, osteomyelitis and epidural abscess. The search for the relevant literature was performed using these search engines: PubMed, ScienceDirect, Ovid, Springer and Google Scholar. The search included the relevant studies published between 1990 and 2019 for the management of PSI.

With this search strategy, 58

Presenting symptoms

The onset of symptoms in patients with PSI is usually insidious. Non-specific symptoms may cause a delay in the diagnosis and treatment.¹⁶ According to Arnold et al. 1997¹⁷ 94% of the patients with PSI included in their study presented initially with a site specific back pain, which was the most common presenting symptom. Lower limb weakness was a presenting problem in 84.9% in this series. Importantly, the mean time from the onset of symptoms till initiation of treatment was around 1 month,

Conclusion

PSI is rare, serious condition that can be caused by many microorganisms. It is most commonly caused by Staphylococcus Aureus. PSI tends to affect elderly or patients with multiple comorbidities. Management of PSI can be either conservative or by surgical intervention.

Conservative management of PSI with adequate duration of antibiotics can result in successful infection resolution in carefully selected patients. There is no consensus about the duration of antibiotics treatment, but there was a

Authors’ contribution

Ahmed Aljawadi: Writing – review & editing, Formal analysis, Literature review, data Analysis, manuscript writing.

Noman Jahangir: Writing – review & editing, Formal analysis, Literature review & Analysis.

Ana Jeelani: Writing – review & editing, Formal analysis, Literature review & Analysis.

Zak Ferguson: Writing – review & editing, Formal analysis, Literature review & Analysis.

Noman Niazi: Writing – review & editing, Formal analysis, Literature review & Analysis.

Frances Arnall: Writing – review

Disclaimer

The authors declare that no part of this study has been taken from existing published or unpublished materials without due acknowledgement and that all secondary materials used herein has been fully referenced.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Spinal infections are still showing increased incidence throughout the years as our surgical capabilities increase, coupled with an overall aging population with greater number of chronic comorbidities. The management of spinal infection is of utmost importance, due to high rates of morbidity and mortality, on top of the general difficulty in eradicating spinal infection due to the ease of hematogenous spread in the spine. We aim to summarize the utility of vacuum-assisted closure (VAC) and local drug delivery systems (LDDS) in the management of spinal infections.
A narrative review was conducted. All studies that were related to the use of VAC and LDDS in Spinal Infections were included in the study.
A total of 62 studies were included in this review. We discussed the utility of VAC as a tool for the management of wounds requiring secondary closure, as well as how it is increasingly being used after primary closure as prophylaxis for surgical site infections in high-risk wounds of patients undergoing spinal surgery. The role of LDDS in spinal infections was also discussed, with preliminary studies showing good outcomes when patients were treated with various novel LDDS.
We have summarized and given our recommendations for the use of VAC and LDDS for spinal infections. A treatment algorithm has also been established, to act as a guide for spine surgeons to follow when tackling various spinal infections in day-to-day clinical practice.
Comparative Clinical Efficacy and Safety of Sacral-2-Alar Iliac Screw Versus Iliac Screw in the Lumbosacral Reconstruction of Spondylodiscitis
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Patients' daily activities have been limited by severe SI, decreasing their quality of life and placing a substantial economic burden on them. It may result from a contiguous etiology (trauma, surgery) or hematogenous spread.15 Lower back pain is the most commonly reported clinical feature in patients with SI, who frequently present with nonspecific symptoms.16
This study aimed to evaluate the clinical efficacy and safety of S2-alar-iliac (S2AI) and iliac screw (IS) techniques in treating lumbosacral spondylodiscitis.
Between January 2020 and January 2022, 28 patients suffering from lumbosacral spondylodiscitis underwent lumbosacral fixation and were divided into the IS group (14 patients) and the S2AI group (14 patients). Surgical details, demographic characteristics, preoperative and postoperative Oswestry Disability Index, visual analog scale, and complications were analyzed.
Twenty-eight patients were included in this study, including 14 patients treated with IS and 14 patients treated with S2AI. The 2 groups were similar in sex, age, follow-up period, total drainage volume, hospitalization stay, and fusion time. (P > 0.05) The estimated blood loss and surgical time of S2AI during surgery were significantly lower than those of IS. (P < 0.05) The visual analog scale and Oswestry Disability Index scores significantly improved in both groups from preoperative to the last follow-up. Sacroiliac joint pain was found in both groups in the follow-up period, but the incidence was not significantly different (P = 0.663). Compared with the IS approach, the incidence of symptomatic screw prominence was lower in the S2AI group, but the difference was not significant. (P = 0.088).
S2AI, as well as IS techniques, can achieve promising results for reconstructing lumbosacral stability in spondylodiscitis. In addition, the S2AI technique can also reduce surgical trauma and operation time.
[Translated article] Analysis of results of open and percutaneous disc biopsy in the diagnosis of spondylodiscitis
2022, Revista Espanola de Cirugia Ortopedica y Traumatologia
Citation Excerpt :
Otherwise, stabilisation and spinal arthrodesis will be necessary.36,37,39 Regarding the technique and approach to instrumentation, different authors emphasise the clinical situation of the patient, the morphology and location of the vertebral lesion and the surgeon's preferences, advocating wide debridement whenever possible.36,37 However, retrospective studies, such as those by Lin et al.43 and Mohamed et al.44 report series of patients treated by decompression and posterior arthrodesis without debridement, followed by strict antibiotic treatment, also with good results.
Spinal disc biopsy is a necessary tool in diagnosing and treating spondylodiscitis. Its profitability varies according to the technique, concomitant antibiotics therapy or causative germ. We studied the results of this procedure in our institution.
Retrospective analysis of all cases requiring disc biopsy due to possible spondylodiscitis over a 5 year period, both percutaneous (26 cases) and open (13 cases). We collected filiation and clinical data, comorbidity, concomitant antibiotic therapy, imaging tests, biopsy type, cultures results and clinical evolution.
39 patients; 66.7% male, 66.9 years of average age. 74% has known risk factors. The main symptom was pain (89.7%). Fever occurred in 5%. MRI performed in 87%. Lumbar involvement in 76.9%. 9 patients (23%) received antibiotic treatment simultaneously with biopsy. In these cases biopsy always yielded a negative result, but positive in patients without antibiotics at the time of the biopsy (53.3%), with statistical significance. Most frequent isolated microorganisms were gram-negative bacilli (31.2%) and gram-positive cocci (31.2%). We found 2 deaths during admission for sepsis (within the first month after diagnosis). Of the rest of patients, 5 died late during the follow-up: 3 due to new infections and 2 due to subsequent complications of previous pathologies. The remaining patients with final diagnosis of spondylodiscitis evolved satisfactorily with antibiotic therapy.
Spondylodiscitis is potentially serious and requires an adequate diagnosis, with disc biopsy being a necessary procedure on occasions. Patients poor clinical condition can make it impossible to withdraw antibiotics, which drastically reduces the performance of the biopsy.
La biopsia discal es una herramienta necesaria en el proceso diagnóstico y terapéutico de las espondilodiscitis. Su rentabilidad es variable según condicionantes como la técnica utilizada, el uso concomitante de antibióticos o el germen causante. Estudiamos los resultados de este procedimiento en nuestro centro en un periodo de 5 años.
Análisis retrospectivo de todos los casos que requirieron biopsia discal por posible espondilodiscitis en nuestro centro entre enero de 2015 y noviembre de 2019, tanto percutánea (26 casos) como abierta (13 casos). Recogemos datos de filiación y clínicos, comorbilidad, antibioterapia concomitante, pruebas de imagen, tipo de biopsia, resultado de cultivos y evolución clínica.
Treinta y nueve pacientes: 66,7% varones, 66,9 años de edad media. El 74% con factores de riesgo conocidos. El síntoma principal es dolor mayoritariamente (89,7%) y fiebre en el 5%. La RMN en la prueba más frecuentemente realizada (87%). Los segmentos lumbares se afectaron en el 76,9%, por el 23% los dorsales. En 9 casos (23%) los pacientes reciben tratamiento antibiótico simultáneamente a la realización de la biopsia. En estos casos la biopsia siempre arrojó un resultado negativo. Los cultivos fueron positivos más frecuentemente en los pacientes sin antibióticos en el momento de la biopsia (53,3%), con significación estadística. Los microorganismos aislados de manera más repetida fueron los bacilos gramnegativos (31,2%) y los cocos grampositivos (31,2%). Constatamos 2 fallecimientos durante el ingreso por sepsis (dentro del primer mes tras el diagnóstico). Del resto de los pacientes fallecieron 5 de manera tardía durante el seguimiento: 3 por nuevas infecciones complicadas de manera tardía y 2 por complicaciones ulteriores de patologías previas. El resto de pacientes con diagnóstico final de espondilodiscitis evolucionaron satisfactoriamente con antibioterapia.
La espondilodiscitis es potencialmente grave y requiere un adecuado diagnóstico, siendo la biopsia discal un procedimiento necesario en ocasiones. Una mala situación clínica del paciente puede imposibilitar la retirada del antibiótico, lo cual disminuye drásticamente el rendimiento de la biopsia.
Severity and Outcome of Neurologic Deficits in Patients with Pyogenic Spondylodiscitis: A Systematic Review
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We discovered neurologic deficits in 52% and epidural abscess in 72% of cervical spondylodiscitis cases. Conventional treatment of spondylodiscitis involves antibiotic therapy for 6 to 12 weeks with surgical intervention reserved for the circumstances with failure of medical management.44,48,51 However, great diligence must be maintained during conservative treatment because the rapid progression of bony destruction, instability, segmental kyphosis, and neurologic deficit will demand the addition of prompt surgical treatment.
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There are no reports of pyogenic spinal infections secondary to an arterioenteric fistula in the literature. Herein, we report a case of recurrent pyogenic spinal infection caused by vascular graft penetration into the sigmoid colon. A 66-year-old man with a history of diabetes and abdominal aortic aneurysm surgery suffered from low back pain and fever. He visited his previous hospital, where a lumbar magnetic resonance imaging revealed a spinal infection. The patient received conservative therapy with antibiotics and underwent several surgeries. However, there was no improvement in his symptoms. The patient was referred to and hospitalized at our university hospital. Because intestinal bacteria were repeatedly detected in his blood cultures, a colonoscopy was performed, which revealed the exposure of a vascular graft in the sigmoid colon confirmed by contrast-enhanced computed tomography. We diagnosed the patient with recurrent pyogenic spinal infection caused by secondary arterioenteric fistula. He then underwent sigmoidectomy, resection of the infected vascular graft, and femoral–femoral artery bypass grafting. There was improvement in his symptoms after the surgery. Gastrointestinal examinations should be performed early when intestinal resident bacteria are detected in blood cultures in patients with pyogenic spinal infections.
Posterior stabilisation without formal debridement for the treatment of non-tuberculous pyogenic spinal infection in frail and debilitated population – A systematic review and meta-analysis
2021, Journal of Clinical Orthopaedics and Trauma
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The first-line treatment of PSI is by conservative measures including antibiotics, spinal support, and bed rest. Surgical intervention should only be considered for patients who failed to respond satisfactorily to the conservative treatment, or if there is any indication for surgery (such as vertebral body collapse with significant deformity, or severe neurological deficit due to compression by an epidural collection).8,27 All patients included in this systematic review have had a trial of conservative management (unless surgery was indicated at presentation), and they were only considered for surgery after failure of conservative measures.
Non-tuberculous pyogenic spinal infection (PSI) incorporates a variety of different clinical conditions. Surgical interventions may be necessary for severe cases where there is evidence of spinal instability or neurological compromise. The primary surgical procedure, for late-stage PSI, focuses on the anterior approach with aggressive debridement of the infected tissue regions. An alternative treatment method that employs a posterior approach without any formal debridement, is seen as controversial. To the best of our knowledge, few case series and no systematic reviews are assessing the value of this posterior technique. We aim to evaluate the effectiveness of the posterior approach without formal debridement and the associated clinical outcomes, for PSI cases requiring surgical intervention.
Several databases including MEDLINE, NHS Evidence, and the Cochrane database were searched from the date of creation of each database to December 16, 2019. A selection of the keywords used includes: “posterior approach”, “debridement” and “discitis”. Studies were excluded if they involved the anterior approach, carried out formal debridement, or were tuberculous spinal infection cases. We accepted any study type which included adult patients, with spinal infection at any level of the vertebral column. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used to follow standard systematic review structure. The main clinical outcomes evaluated include pain, neurological recovery (Frankel Grading System, FGS) post-operative complications, and functional outcomes (Kirkaldy-Willis Criteria and Spine Tango Combined Outcome Measure Index, COMI).
Post-surgical neurological improvement was demonstrated with a mean FGS improvement of 1.12 in 102 patients over the included four articles. Post-operative neurological function was found to be improved at a statistically significant level when a random-effects model was applied, with the effect size found to be at 0.68 (p < 0.001). Pain level was improved significantly postoperatively. There were also enhanced functional outcomes post-intervention when the Kirkaldy-Willis criteria and COMI scores were assessed in certain studies.
Within the limit of the available literature, our results showed that the posterior approach with posterior stabilisation without formal debridement can result in successful infection resolution, improved pain scores and neurological outcomes. However, Larger series with longer follow-up duration is strongly recommended.

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Management of Pyogenic Spinal Infection, review of literature

Abstract

Objective

Methods and results

Conclusion

Introduction

Section snippets

Method and results

Presenting symptoms

Conclusion

Authors’ contribution

Disclaimer

Funding

Spine J

J Infect Public Health

Surg Neurol

Surg Neurol

J Infect

Surg Neurol

J Infect

Spine J

J Infect Chemother

Spine J

Jt Bone Spine

Spine J

World Neurosurg

Successful treatment of spondylodiscitis using titanium cages: a 3-year follow-up of 22 consecutive patients

Acta Orthop

Hematogenous pyogenic spinal infections and their surgical management

Spine

Vertebral osteomyelitis

N Engl J Med

Posterior lumbar interbody fusion with an autogenous iliac crest bone graft in the treatment of pyogenic spondylodiscitis

J Bone Joint Surg Br Vol

Clinical outcome of posterolateral endoscopic surgery for pyogenic spondylodiscitis: results of 15 patients with serious comorbid conditions

Spine