Comparison of the Results between Conservative and Operative Treatments for Pyogenic Spondylitis / 대한정형외과학회잡지

PURPOSE: With advancements in antibiotics, the ability to treat pyogenic spondylitis is increasing. This study aimed to compare and analyze the outcomes between conservative and operative treatments. MATERIALS AND METHODS: Sixty patients (28 males and 32 females) with pyogenic spondylitis, who were hospitalized and treated between February 2008 and June 2016, were enrolled. Patients were divided according to the following: type of treatment – conservative or operative treatment, method of surgery, radiographic parameters, location of the affected spine. Clinical parameters as durations of hospital stay, intravenous antibiotics use, normalization in laboratory findings, and residual symptoms were analyzed. For statistical evaluation, independent-sample t-test, Mann-Whitney U-test, Pearson's chi-square test, one-way ANOVA, and Spearman correlation analysis were performed retrospectively. RESULTS: There was no significant difference in the duration of hospital stay, intravenous antibiotics use, normalization in laboratory findings, and residual symptoms between the conservative and operative treatment groups. CONCLUSION: In treating pyogenic spondylitis, conservative treatment can be considered as the first choice, and operative treatment can be chosen in refractory cases.

Conservative Treatment of Pyogenic Spondylitis in the Elderly

STUDY DESIGN: Retrospective study. OBJECTIVES: To analyze the outcomes of conservative management in elderly patients over 65 years of age who were diagnosed with pyogenic spondylitis. SUMMARY OF LITERATURE REVIEW: The surgical treatment of pyogenic spondylitis can lead to complications in elderly patients in a poor general condition or with underlying diseases. MATERIALS AND METHODS: We performed a retrospective review of 32 patients who were diagnosed with pyogenic spondylitis and had a minimum of 12 months of follow-up. Age, sex, comorbidities, clinical symptoms, and the involved segments were analyzed retrospectively. The diagnosis was assessed using clinical, laboratory, and radiologic findings. Antibiotic therapy was either specific (if positive culture results were found) or broad-spectrum cephalosporin (when the pathogenic agent was not isolated). Outcomes were assessed using residual pain and neurologic deficits. RESULTS: The mean onset time was 23.5 days (range, 3-90 days). The mean period of intravenous antibiotic therapy was 36.3 days (range, 10-90 days). All cases underwent conservative management, and 4 patients with progressive neurologic deficits due to epidural abscess underwent posterior laminectomy and abscess drainage. In all cases, the infection was successfully treated, although 12 cases reported residual lower back pain and 2 continued to exhibit minor neurologic deficits. CONCLUSIONS: In elderly patients with pyogenic spondylitis, satisfactory results were obtained with conservative management using antibiotics and orthosis after an early diagnosis, unless progressive neurologic symptom instability or spine deformities were noted.

Late Pyogenic Spondylitis after Vertebroplasty with PMMA-filled Adjacent Segments: A Case Report

OBJECTIVES: To report a rare case of late pyogenic spondylitis around the cement mass in T12 that developed 4 years after vertebroplasty with L1-3 bodies already filled with cement due to previous vertebroplasty. SUMMARY OF LITERATURE REVIEW: Pyogenic spondylitis after vertebroplasty is a rare complication, but very difficult to manage. MATERIALS AND METHODS: A 56-year old female visited us with pyogenic spondylitis around the T12 body. The bodies of L1-L3 had been filled with cement eight years previously, followed by another vertebroplasty for T12 four years previously in a local clinic. At first, conservative management with intravenous antibiotics was attempted for 8 weeks, without clinical improvement. Therefore, anterior surgery for T12 corpectomy, removal of the cement, and fusion was performed. RESULTS: The infection was cured and anterior fusion was achieved, and the patient was able to return to her previous activities. CONCLUSIONS: Though previous vertebroplasty of the adjacent vertebral body seemed to be a major obstacle to achieving fusion, anterior surgical treatment was the ultimate solution to this complex problem.

Analysis of clinical characteristics of 20 patients with pyogenic spondylitis / 中国骨伤

<p><b>OBJECTIVE</b>To investigate the diagnostic value of clinical manifestation, laboratory examination and imaging changes for pyogenic spondylitis and to summarize the clinical characteristics of patients with pyogenic spondylitis.</p><p><b>METHODS</b>The clinical data, of 20 patients with pyogenic spondylitis were diagnosed by histopathological examination from March 2012 to March 2015, were retrospectively analyzed. There were 9 males and 11 females, aged from 43 to 72 years old with an average of 58.9 years. Included 3 cases of cervical vertebrae, 7 cases of thoracic vertebrae, 10 cases of lumbar vertebrae. Patients of blood analysis, erythrocyte sedimentation rate(ESR), C reactive protein(CRP), X rays, CT and MRI were performed before treatment. Visual analogue scale (VAS) was used to evaluate the pain of patients suffering from vertebral pain.</p><p><b>RESULTS</b>All the patients had suffered from vertebral pain before treatment. VAS was 9 points in 4 cases, 8 points in 6 cases, 7 points in 1 case, 3 points in 6 cases, and 2 points in 3 cases. Among them, 7 patients complicated with neurological symptoms, 11 with aggravating night pain, 10 with fever. WBC and Neutrophil count (NEU) of 5 cases were increased and other 15 cases were normal;CRP of 19 cases were increased and 1 case was normal;ESR of all 20 cases were increased. X rays showed the intervertebral space narrowing in all 20 cases, 13 cases complicated with destruction of vertebral body; CT showed the lesions of vertebral body in the 20 cases and complicated with destruction, sclerosis of sclerotin; MRI showed that the lesions of the vertebral body in the T1 image had uneven medium low signal, in the T2 image of the 16 cases had uneven high signal and 2 cases had uniform and high signal, 2 cases had main high signal compliated with mixed signal. Thirteen patients underwent surgical treatment and 7 patients received conservative treatment, and the patients left hospital while VAS had significantly improved after treatment.</p><p><b>CONCLUSIONS</b>Pyogenic spondylitis is easy to be misdiagnosed or missed in clinic. It can be combined with the clinical manifestations, laboratory examination and imaging characteristics in order to make a definite diagnosis for purulent spondylitis in early.</p>

CT differentiation between tuberculous spondylitis and pyogenic spondylitis / 实用放射学杂志

Objective This study was to investigate the computed tomography(CT)features differentiating tuberculous spondyli-tis from pyogenic spondylitis.Methods The CT features in 32 patients with tuberculous spondylitis and 30 patients with pyogenic spondylitis were retrospectively reviewed,and statistically analyzed.Results In 32 cases of tuberculous spondylitis,71 vertebra were involved.In 30 cases of pyogenic spondylitis,59 vertebra were involved.The incidence of thoracic vertebra involvement in tuberculous spondylitis was 60.56% (43/71),which was higher than that in pyogenic spondylitis (25.42%,1 5/59)(P <0.05).The incidence of lumbar vertebra involvement in tuberculous spondylitis was 33.80% (24/71 ),which was lower than that in pyogenic spondylitis (61.02%,36/59)(P <0.05).The incidence of the worm-eaten type of bone destruction in tuberculous spondylitis was 9.90% (7/71),which was lower than that in pyogenic spondylitis (44.07%,26/59)(P <0.05).The incidence of the fragmentary type of bone destruction in tuberculous spondylitis was 1 9.72%(14/71 ),which was higher than that of in pyogenic spondylitis (3.39%,2/59) (P <0.05).The incidence of large osteosclerosis in tuberculous spondylitis was 52.1 1%(37/71),which was higher than that in pyo-genic sp-ondylitis (22.03%,13/59),(P <0.05).The incidence of the involved vertebral height on sagital CT scan (less than the 1/2 of the normal vertebral height)in tuberculous spondylitis was 1 6.9% (12/71),which was lower than that in pyogenic spondylits (62.71%,37/59)(P <0.05).The incidence of patchy high density shadow in tuberculous spondylitis was 50.7% (36/71 ),which was higher than that in pyoge-nic spondylitis (20.34%,12/59)(P <0.05.)The incidence of the involvement of the appendages in tu-berculous spondylitis was 25.35% (18/71),which was higher than that in pyogenic spondylitis (8.47%,5/59)(P <0.05).The inci-dence of paravertebral abnormal soft tissue with calcification in tuberculous spondylitis was 60.00%(18/30),which was higher than that in pyogenic spondylitis(20.00%,5/25 )(P < 0.05 ).Conclusion Tuberculous spondylitis and pyogenic spondylitis have some characteristic imaging features,combined with the clinical signs differentiation diagnosis can be made each other.

A Case of Pyogenic Spondylitis Due to Aggregatibacter aphrophilus / 대한임상미생물학회지

Aggregatibacter aphrophilus, a normal component of oral cavity flora, mostly causes infective endocarditis and only rarely causes spondylitis; no spondylitis cases have been previously reported in Korea. We report a case of pyogenic spondylitis due to A. aphrophilus without endocarditis. A 64-year-old man was admitted for back pain lasting 3 weeks. There was severe tenderness on lumbar spines but no fever. Laboratory evaluation showed leukocytosis and elevated C-reactive protein. Blood cultures were negative. Magnetic resonance imaging showed psoas abscess and vertebral inflammation. Pus was obtained by computerized tomography-guided aspiration from the psoas abscess and inoculated into blood culture bottles. After 5 days of incubation, growth was detected: the isolate was a Gram-negative short rod bacteria identified as A. aphrophilus by the automated system; this was confirmed by 16S ribosomal RNA sequencing. There was no evidence of endocarditis in echocardiography and retinal examination. Back pain persisted despite 8 weeks of antibiotic treatment, so vertebral corpectomy was performed. A. aphrophilus, a rare cause of pyogenic spondylitis, can induce spondylitis without endocarditis. If a patient with pyogenic spondylitis shows negative routine bacterial cultures, fastidious organisms such as A. aphrophilus should be suspected and the blood culture bottles could be used.

Comparison of Pyogenic Spondylitis and Tuberculous Spondylitis

Pyogenic spondylitis and tuberculous spondylitis are common causes of spinal infection. It is difficult to differentiate tuberculous spondylitis and pyogenic spondylitis clinically and radiologically. Recently magnetic resonance imaging has been reported to be beneficial for early diagnosis and differential diagnosis of the spondylitis, and is being used extensively for diagnosis. However, the diagnosis must be considered in combination with corresponding changes in clinical manifestations, radiological findings, blood and tissue cultures and histopathological findings. Conservative treatments, including antimicrobial medications, are started initially. Surgical treatments, which include anterior or posterior approach, single-stage or two-stage surgery, with or without instrumentation, may be performed as indicated.

Weekly Teriparatide Therapy Rapidly Accelerates Bone Healing in Pyogenic Spondylitis with Severe Osteoporosis

Pyogenic spondylitis is a frequently observed disease in orthopedics, and the number of cases is increasing. Some patients with pyogenic spondylitis suffer from vertebral destruction due to infection. The disease is typically treated with antibiotics, bed rest, spinal support, and lesion curettage; however, vigorous drug therapy against vertebral body destruction by pyogenic spondylitis has not been attempted. In this report, a case of pyogenic spondylitis with spinal destruction caused by infection and treated with once-weekly teriparatide administration is presented. Vertebral body erosion in cortical and cancellous areas by the infection was rapidly repaired after 6 weeks of once-weekly teriparatide treatment. Treatment with once-weekly teriparatide appears to be a new strategy for patients with severe osteoporosis suffering from pyogenic spondylitis.

Weekly Teriparatide Therapy Rapidly Accelerates Bone Healing in Pyogenic Spondylitis with Severe Osteoporosis

Pyogenic spondylitis is a frequently observed disease in orthopedics, and the number of cases is increasing. Some patients with pyogenic spondylitis suffer from vertebral destruction due to infection. The disease is typically treated with antibiotics, bed rest, spinal support, and lesion curettage; however, vigorous drug therapy against vertebral body destruction by pyogenic spondylitis has not been attempted. In this report, a case of pyogenic spondylitis with spinal destruction caused by infection and treated with once-weekly teriparatide administration is presented. Vertebral body erosion in cortical and cancellous areas by the infection was rapidly repaired after 6 weeks of once-weekly teriparatide treatment. Treatment with once-weekly teriparatide appears to be a new strategy for patients with severe osteoporosis suffering from pyogenic spondylitis.

Is Titanium Mesh Cage Safe in Surgical Management of Pyogenic Spondylitis?

OBJECTIVE: To report our experience with pyogenic spondylitis treated with anterior radical debridement and insertion of a titanium mesh cage and to demonstrate the effectiveness and safety of the use of a titanium mesh cage in the surgical management of pyogenic spondylitis. METHODS: We retrospectively analyzed the clinical characteristics of 19 patients who underwent surgical treatment in our department between January 2004 and December 2008. The average follow-up period was 11.16 months (range, 6-64 months). We evaluated risk factors, cultured organisms, lab data, clinical outcomes, and radiographic results. Surgical techniques for patients with pyogenic spondylitis were anterior radical debridement and reconstruction with titanium mesh cage insertion and screw fixation. All patients received intravenous antibiotics for at least 6 weeks postoperatively, and some patients received oral antibiotics. RESULTS: The infections resolved in all of the patients as noted by normalization of their erythrocyte sedimentation rates and C-reactive protein levels. The mean pain score on a Visual Analog Scale was 7.8 (range, 4-10) before surgery and 2.4 (range, 1-5) after surgery. The Frankel grade was improved by one grade in seven patients. After surgery, the average difference of the angle was improved about 6.96degrees in all patients. At the last follow-up, the mean loss of correction was 4.86degrees. CONCLUSION: Anterior radical debridement followed by the placement of instrumentation with a titanium mesh cage may be a safe and effective treatment for selected patients with pyogenic spondylitis. This surgical therapy does not lead to recurrent pyogenic spondylitis.

Delayed Diagnosis of Tuberculous Spondylitis Masked by Concomitant Methicillin Resistant Staphylococcus Aureus Infection

We present a case of tuberculous spondylitis in which diagnosis was masked by a concomitant pyogenic infection. The patient had undergone percutaneous needle aspiration of an abscess in the cavity of the psoas muscle. Early results from the culture regimen showed isolation of methicillin-resistant Staphylococcus aureus. After eight weeks, mycobacterium tuberculosis was grown at regimen which was cultured at the same site. Initial isolation of pyogenic bacteria, considered to be highly virulent organisms, led to delayed diagnosis and treatment of the tuberculosis.

Acute low back pain revealed as pyogenic spondylitis: A report of 2 cases

Many people suffer from low back pain and that has caused much socioeconomic cost. As a non specific cause of low back pain, an increase in the incidence of pyogenic spondylitis has been noticed. Early radiological diagnosis is of great importance for prompt treatment and prevention of clinically significant consequences which include neurological deficit and secondary spine deformity. We describe two cases of pyogenic spondylitis with epidural abscess. The former case, we could not make an early diagnosis and proper management was delayed. Fortunately, no neurologic deficits were remained. On contrast, the latter was promptly diagnosed as a pyogenic spondylitis and proper treatment was established. Most of all, careful preliminary evaluation, especially laboratory data and analysis of radiologic findings are important prognostic factor in treatment patient for pyogenic spondylitis.

Management of Lumbar Pyogenic Spondylitis with Posterior Decompression and Interbody Fusion Using Transpedicular Screws / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to assess the efficacy of posterior decompression and interbody fusion with posterior instrumentation in treating lumbar pyogenic spondylitis. MATERIALS AND METHODS: Twenty-one patients with lumbar pyogenic spondylitis who underwent posterior decompression and lumbar interbody fusion with posterior fixation were reviewed. Clinically infection control (CRP normalization time) and rehabilitation were investigated. And radiologically, timing of achievement of fusion and changes of sagittal alignment were investigated. RESULTS: Infection was controlled successfully without any recurrence and breakage of instrument. Stable interbody fusion was achieved in all cases within 6 months. Postoperative interval to achieve normal CRP was 28.7 (10-64) days. Ambulation was started on 5.8th (2-19) day. Sagittal angle was 12.3 degrees before operation, became more lordotic to 16.4 degrees, but decreased to 11 degrees at final follow-up. Final sagittal alignment was almost same with the preoperative status. CONCLUSION: By achieving favorable results clinically and radiologically, posterior decompression and interbody fusion seemed to be an effective method in management of lumbar pyogenic spondylitis.

Differential Diagnosis between Tuberculous Spondylitis and Pyogenic Spondylitis / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study OBJECTIVES: We wanted to make the early differential diagnosis between tuberculous spondylitis and pyogenic spondylitis according to the clinical and MRI findings. SUMMARY OF THE LITERATURE REVIEW: Making an early differential diagnosis between tuberculous spondylitis and pyogenic spondylitis is essential to start prompt and proper treatment. However, the clinical symptoms and MRI findings of both these illnesses can vary considerably. MATERIAL AND METHOD: Ninety-five patients (49 men and 46 women, mean age: 54.5) who were treated from January 2001 to February 2007 and whose diagnosis was confirmed by laboratory or pathological studies were retrospectively reviewed. 50 patients with tuberculous spondylitis and 45 patients with primary pyogenic spondylitis were included. The patients with combined infection or an uncertain diagnosis were excluded. We compared the medical records and MRI findings between the different groups of patients. RESULTS: The patients with tuberculous spondylitis were younger (48.2 years vs. 61.5 years, respectively) and they had a longer symptom duration (4.3 months vs 1.8 months, respectively). The erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level were significantly higher in the patients with pyogenic spondylitis (71.3/49.6 mm/hr and5.74/2.98 mg/dl, respectively). A high fever above 38 degree was more frequent in the patients with pyogenic spondylitis. Intraosseous abscess, epidural abscess, a well-definded paraspinal abscess, focal enhancement and severe destruction of the vertebral body on MRI were more frequent in the patients with tuberculous spondylitis. Four parameters such as a symptom duration longer than 3 months, no fever higher than 38 degree, a well-defined paravertebral abscess and an intraosseous abscess were selected. 42 patients in the tuberculous group had 3 or more of these four parameters. The sensitivity and specificity of these combined 4 parameters were 84% and 97.8%, respectively, for making the differential diagnosis between these 2 maladies. CONCLUSION: These diagnostic criteria might be useful to discriminate between tuberculous spondylitis and pyogenic spondylitis even without definite laboratory or pathological results.

A Case of Spondylodiskitis Caused by Injection Site Infection with Methicillin-Resistant Staphylococcus aureus / 감염과화학요법

Infections of the intervertebral disc and adjacent vertebrae may present with spondylitis, discitis and spondylodiscitis and are hematogenous origin in most cases. Potential sources of hematogenous infection are skin and soft tissue infection, genitourinary tract infection, infective endocarditis, intravenous drug abuse, respiratory tract infection and infected intravenous injection site. We have experienced a case of pyogenic spondylitis caused by methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with peripheral injection site infection. He was successfully treated with surgical debridement and antibiotics.

A Case of Spondylodiskitis Caused by Injection Site Infection with Methicillin-Resistant Staphylococcus aureus / 감염과화학요법

Infections of the intervertebral disc and adjacent vertebrae may present with spondylitis, discitis and spondylodiscitis and are hematogenous origin in most cases. Potential sources of hematogenous infection are skin and soft tissue infection, genitourinary tract infection, infective endocarditis, intravenous drug abuse, respiratory tract infection and infected intravenous injection site. We have experienced a case of pyogenic spondylitis caused by methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with peripheral injection site infection. He was successfully treated with surgical debridement and antibiotics.

Diagnosis and Treatment of Tuberclous Spondylitis and Pyogenic Spondylitis in Atypical Cases

STUDY DESIGN: A retrospective study. PURPOSE: This is a study of the diagnosis and treatment of tuberculous spondylitis and pyogenic spondylitis in atypical cases. OVERVIEW OF LITERATURE: There have been several reports about clinical, hematological, pathological and radiological findings to differentiate pyogenic & tuberculous spondylitis. METHODS: We screened 55 patients diagnosed with tuberculous spondylitis and pyogenic spondylitis from January 1999 to June 2003. There were seven cases where it was difficult to make an accurate diagnosis. We reviewed the clinical manifestation, laboratory tests, radiological findings and confirmed the diagnoses by the use of biopsies and/or clinical response to treatment. RESULTS: Four cases, which were initially diagnosed as pyogenic spondylitis, had a clinical presentation of fever (37.4~38.5degrees C) on the day of hospitalization. These cases later turned out to be tuberculous spondylitis, as confirmed by an open biopsy and pathologic study. Three cases initially diagnosed as pyogenic spondylitis were treated with broad-spectrum antibiotics. Symptoms were aggravated in these cases, but improved after the use of an anti-tubercular drug. Bony union was observed in all cases in an averageof 4 months (range, 3~6 months). CONCLUSIONS: In infectious spondylitis, it is important to establish an accurate diagnosis. An accurate diagnosis can be made by laboratory findings and by estimation of the response to treatment during follow-up. If there is no response or aggravation of symptoms despite treatment based on an initial diagnosis, the etiologic organism must be re-evaluated. A biopsy and observation of clinical response are needed to confirm the diagnosis.

Anterior Debridement and Strut Graft with Pedicle Screw Fixation for Pyogenic Spondylitis

STUDY DESIGN: A retrospective study. PURPOSE: We evaluated the results of the use of anterior debridement and interbody fusion followed by posterior spinal instrumentation. OVERVIEW OF LITERATURE: An early diagnosis of pyogenic spondylitis is difficult to obtain. The disease can be treated with various surgical methods (such as anterior debridement and bone graft, anterior instrumentation, and posterior instrumentation). METHODS: This study included 20 patients who received anterior debridement and interbody fusion with strut bone graft followed by posterior spinal fusion for pyogenic spondylitis between 1996 and 2005. We analyzed the culture studies, the correction of the kyphotic angle, blood chemistry, the bony union period, and the amount of symptom relief. RESULTS: In terms of clinical symptoms relief, eight patients were grouped as "excellent", eleven patients as "good", and one patient as "fair". The vertebral body cultures were positive in 14 patients showing coagulase (-) streptococcus and S. aureus. The average times for normalization of the erythrocyte sedimentation rate and C-reactive protein level were 3.3 and 1.9 months, respectively. Four months was required for bony union. For complications, meralgia paresthetica was found in two cases. CONCLUSIONS: Due to early ambulation and the correction of the kyphotic angle, anterior interbody fusion with strut bone graft and posterior instrumentation could be another favorable method for the treatment of pyogenic spondyulitis.

Pyogenic Spondylitis after Vertebroplasty: A Report of Two Cases

Vertebroplasty is now extensively used worldwide for thoracic and lumbar osteoporotic compression fractures. Although percutaneous vertebroplasty is considered a minimally invasive procedure, it may result in several complications. In this report, we present two patients where pyogenic spondylitis developed after vertebroplasty surgery was required. The serious nature of these infections, surgical management and complication avoidance are discussed.

Preoperative Gadolinium-enhanced Magnetic Resonance Images on Infectious Spondylitis

OBJECTIVE: The purpose of this study is to analyze the patterns of intervertebral disc enhancement seen in infectious spondylitis, differentiate between two groups(tuberculous vs pyogenic spondylitis). METHODS: Between January 1994 and December 2002, 83patients underwent operative procedure with confirmed to histopathologic evaluation. Magnetic resonance(MR) images were obtained in all patients and were analyzed retrospectively. 57patients had tuberculosis and 26patients were infected by pyogens. The patterns of gadolinium enhancement of disc were classified into 4 types(post's classification): Type I, non-enhancing; Type II, enhancement of the peripheral rim; Type III, Type II with central area and partial endplate; Type IV, general enhancement. RESULTS: The enhancement patterns observed were as follows: Common pattern of tuberculous spondylitis was Type II, and pyogenic spondylitis was Type III.(p<0.01) This difference may result from pathophysiologic varieties of organisms. CONCLUSION: Careful preoperative MR analysis of the patterns of disc enhancement occuring in infectious spondylitis can be useful for differentiating between the tuberculous and pyogenic spondylitis.