Comparative outcomes of operative relative to medical management of spondylodiscitis accounting for frailty status at presentation.

PURPOSE: Investigate outcomes in a spondylodiscitis (SD) patient cohort undergoing operative and medical treatment or medical treatment alone, accounting for frailty status at presentation. METHODS: Patients >18 years old undergoing treatment for SD were retrospectively analyzed. The diagnosis of SD was made through a combination of clinical findings, MRI/CT findings, and blood/tissue cultures. Those who failed to respond to antibiotics, had deteriorating markers, or developed neurologic compromise were considered operative candidates. Patients were stratified based on operative (Op, operative plus medical management) or conservative (Cons, medical only) treatment. Univariate analyses identified differences in outcome measures across treatment groups. Conditional forward regression equations, controlling for patient age, identified predictors of increased mortality and inferior outcomes. RESULTS: 116 patients with SD were included. 73 underwent Cons treatment and 43 were Op. Op patients were significantly younger (62.9vs70.7yrs; p < 0.001) and less frail (1.09vs1.85; p < 0.006) than Cons patients, with significantly higher WCC and ESR. Cons pts had higher rates of isolated SD, but Op pts had higher rates of SD with associated SEA, VOM, psoas abscess, and para-vertebral abscess (all p < 0.05). Op pts had significantly lower 30-day mortality than Cons pts (2.3%vs17.8%, p = 0.016), and trended lower 1Y mortality (11.6%vs20.5%, p = 0.310) with similar SD recurrence rates (11.6%vs16.4%, p = 0.592). Patients with an mFI > 3 had significantly higher 30-day mortality (30.4% vs 7.5%, p = 0.003) and trended higher 1-year mortality regardless of intervention. CONCLUSIONS: Operative intervention was associated with lower 30-day mortality significantly and 1-year mortality compared to conservative treatment, while an increased mFI was associated with higher short-term mortality.

Risk factors associated with poor clinical outcome in pyogenic spinal infections: 5-years' intensive care experience.

INTRODUCTION: Management of pyogenic spinal infections (PSI) after the development of neurological deficit has not been specifically addressed in the literature. We aimed to describe real-life clinical outcomes of PSI in patients admitted to an intensive care unit with neurological deficit and identify factors associated with good prognosis. METHODOLOGY: Consecutive patients admitted to ICU with a possible diagnosis of spinal infection over five years' period were included. Descriptive statistics were performed to examine the demographics and clinical parameters. RESULTS: The majority (71%) of patients were male. The mean age was 57.4 years (27-79), and 71% were > 50 years old. At least one underlying risk factor was identified in 68% of the patients; the most common comorbidity was diabetes mellitus (DM). All patients have presented with fever accompanied by a neurological deficit (86%) and back pain (79%). A complete recovery was achieved in 25% of patients. However, the majority of patients had adverse outcomes with 21.4% mortality, and 43% remaining neurological sequelae. Increased age with a cut-off of 65 years and pre-existing DM were identified as being associated with poor outcome. CONCLUSION: Mortality among patients admitted to ICU with PSI was significantly higher than reported in the literature. The residual neurological deficit was common, one-third of patients had remaining neurological sequelae, and only one-fourth had complete recovery. Increased age and background DM were the most important determinants of poor clinical outcome. The impact of DM appears to be much more important than currently recognised in this population.

Clinical manifestations and outcomes of musculoskeletal nontuberculous mycobacterial infections.

To investigate the clinical manifestations and outcomes of musculoskeletal (MSK) nontuberculous mycobacterium (NTM) infections. This study was a retrospective cohort study using the Siriraj Hospital database from 2005 to 2017. Enrolled were all patients aged 15 or older who had an MSK infection with NTM identified in synovial fluid, pus, or tissue by an acid-fast bacilli stain, culture, or polymerase chain reaction. Of 1529 cases who were diagnosed with NTM infections, 39 (2.6%) had an MSK infection. However, only 28 patients met our inclusion criteria. Their mean age (SD) was 54.1 (16.1) years, and half were male. Of this cohort, 25% had previous musculoskeletal trauma, 18% prior bone and joint surgery, 14% prosthetic joint replacement, and 11% HIV infection. The median symptom duration (IQR) was 16 (37.4) weeks. The most common MSK manifestation was arthritis (61%), followed by osteomyelitis (50%), tenosynovitis (25%), and spondylodiscitis (14%). The most common organism was M. abscessus (18%), and M. kansasii (18%), followed by M. intracellulare (14%), M. marinum (14%), M. fortuitum (7%), and M. haemophilum (7%). In addition to medical treatment, most patients underwent surgery (82%), comprising debridement, osteotomy, prosthesis removal, and amputation, while 18% received only medical treatment. The treatment outcomes were complete recovery in 46%, improvement with some residual disability and deformities in 29%, and death in 3.6%. Musculoskeletal NTM infections were uncommon. Most patients had underlying joint disease or were immunocompromised hosts. Surgical management, as an adjunct to medical therapy, was necessary.

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group.

BACKGROUND: Cervical spondylodiscitis is a rare but severe complication of pharyngeal surgery. MATERIAL AND METHODS: This multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017. OBJECTIVES: To describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications. RESULTS: Seven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6days. The interval between surgery and spondylodiscitis diagnosis ranged from 20days to 4.5months, for a mean 2.1months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%). CONCLUSION: This French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.

Espondilodiscitis infecciosa primaria en 51 pacientes mayores de 75 años: estudio comparativo / Primary infectious spondylodiscitis in 51 patients over 75 years old: A comparative study

Antecedentes y objetivo: Se ha demostrado que la incidencia de la espondilodiscitis infecciosa se incrementa con la edad; sin embargo, esto no ha sido investigado ampliamente en los mayores. Material y métodos: Estudio retrospectivo, en un único centro, que incluyó a los pacientes hospitalizados en nuestro Departamento de Reumatología debido a espondilodiscitis infecciosa entre 2000 y 2015, y comparación de los pacientes mayores de 75 con los pacientes más jóvenes. Resultados: De los 152 pacientes, 51 (33,6%) eran≥75 años, 59 de entre 61 y 74, y 42≤60. Los pacientes≥75 estaban frecuentemente institucionalizados (7,8 frente a 0; p=0,02), estuvieron menos sujetos a los factores de riesgo de infección (27,5 frente a 54,5%; p=0,02), pero no difirieron del resto en cuanto a la frecuencia de diabetes y cáncer. El tiempo de diagnóstico fue menor para los pacientes menores de 60 años (23 frente a 30 frente a 30 días para cada grupo de edad, respectivamente; p<0,05). No se produjeron diferencias entre los grupos de edad en términos de localización de la espondilodiscitis, frecuencia de síntomas neurológicos y fiebre, frecuencia o intensidad del síndrome inflamatorio, toma de imágenes, frecuencia de identificación de microorganismos, positividad del hemocultivo, o uso o eficacia de la biopsia discovertebral. La distribución de los microorganismos fue comparable entre los grupos, exceptuando los bacilos gramnegativos, siendo Escherichia coli el más común en los pacientes mayores de 75 años (7/8 frente a 414; p=0,02). La duración del tratamiento antibiótico y la hospitalización fueron comparables entre los grupos de edad. Cinco pacientes fallecieron, todos ellos mayores de 75 años (5/51 frente a 0/101; p=0,001). Conclusión: La edad es un factor de riesgo para la espondilodiscitis primaria, que se asocia a una mortalidad significativa en los pacientes mayores de 75 años (10%). Para estos pacientes mayores, la espondilodiscitis no comporta otras características distintivas

Background and objetive: The incidence of infectious spondylodiscitis has been shown to rise with age; however, they had not been extensively investigated in the very elderly. Material and methods: This retrospective, monocentric study included patients hospitalized in our department of rheumatology for primary infectious spondylodiscitis between 2000 and 2015, and compared over 75-year-olds with younger patients. Results: Of the 152 patients, 51 (33.6%) were≥75 years old, 59 were 61-74, and 42 were≤60. Patients≥75 years old were more often institutionalized (7.8 vs. 0; P=.02), were less often subject to infection risk factors (27.5 vs. 54.5%; P=.02), but did not differ from the others as regards the frequency of diabetes and cancer. Time to diagnosis was shorter for the under 60-year-olds (23 vs. 30 vs. 30 day for each age group, respectively; P<.05). There were no differences among the age groups in terms of spondylodiscitis localization, frequency of neurological symptoms and fever, frequency or intensity of inflammatory syndrome, imaging use, frequency of microorganism identification, blood culture positivity, or use and efficacy of disco-vertebral biopsy. Microorganism distribution was comparable among the groups, except for Gram-negative bacilli, with Escherichia coli more common in over 75-year-olds (7/8 vs. 4/14; P=.02). Duration of antibiotherapy and hospitalization was comparable across the age groups. Five patients died, all over 75 years old (5/51 vs. 0/101; P=.001). Conclusion: Age is a risk factor for primary spondylodiscitis, associated with significant mortality in over 75-year-olds (10%). For these elderly patients, spondylodiscitis does not bear any other distinguishing features

[Spondylodiscitis : Current strategies for diagnosis and treatment]. / Spondylodiszitis : Aktuelle Strategien zur Diagnose und Therapie.

Spondylodiscitis is a severe infectious disease of the intervertebral discs and of the adjacent parts of the vertebral bodies, culminating in destruction of the mobile segment. It is accompanied by a mortality rate of approximately 15%. Severe courses of the disease can also lead to abscess formation and dispersal of sepsis. Malpositioning of the axis organ and deficits in neurological function up to paraplegia are also possible complications. Timely diagnostics and targeted therapy contribute to minimizing the risk of significant health disorders. This review article gives a summary of important algorithms in the diagnostics and treatment and discusses them against the background of currently available literature. According to the current state of knowledge the surgical treatment of spondylodiscitis provides many advantages and is therefore the method choice, even if a conservative approach can be successful in selected cases. The endpoints of treatment are cleansing of the infection with normalization of laboratory parameters of inflammation and the osseous fusion of the mobile segment.

Mortality and health-related quality of life in patients surgically treated for spondylodiscitis.

PURPOSE: To assess mortality, disability, and health-related quality of life (HRQL) in patients surgically treated for spondylodiscitis. METHODS: A retrospective longitudinal study was conducted on all patients surgically treated for spondylodiscitis over a 6-year period at a single tertiary spine center. Indications for surgery, pre- and postoperative neurological impairment, comorbidities, and mortality were recorded. A survey was conducted on all eligible patients with the EuroQol 5-dimension (EQ-5D) questionnaire and Oswestry Disability Index (ODI). RESULTS: Sixty-five patients were diagnosed with spondylodiscitis not related to recent spine surgery. One-year mortality rate was 6%. In all, 36% and 27% had pre- and postoperative neurological impairment, respectively, with only one patient experiencing deterioration postoperatively. At final follow-up (median 2 years), mean ODI was 31% (SD = 22) and mean EQ-5D time trade-off score was 0.639 (SD = 0.262); this was significantly lower than that in the normal population ( p < 0.001). Patients with neurological impairment prior to index surgery had lower EQ-5D scores ( p = 0.005) and higher ODI ( p = 0.02) at final follow-up compared with patients without neurological impairment. CONCLUSIONS: Several years after surgery, patients surgically treated for spondylodiscitis have significantly lower HRQL and more disability than the background population. Neurological impairment prior to index surgery predicts adverse outcome in terms of disability and lower HRQL.

Long-term prognosis and causes of death after spondylodiscitis: A Danish nationwide cohort study.

BACKGROUND: Data on long-term prognosis after spondylodiscitis are scarce. The purpose of this study was to determine long-term mortality and the causes of death after spondylodiscitis. METHODS: A nationwide, population-based cohort study using national registries of patients diagnosed with non-post-operative pyogenic spondylodiscitis from 1994-2009, alive 1 year after diagnosis (n = 1505). A comparison cohort from the background population individually matched for sex and age was identified (n = 7525). Kaplan-Meier survival curves were constructed and Poisson regression analyses used to estimate mortality rate ratios (MRR). RESULTS: Three hundred and sixty-five patients (24%) and 1115 individuals from the comparison cohort (15%) died. Unadjusted MRR for spondylodiscitis patients was 1.76 (95% CI = 1.57-1.98) and 1.47 (95% CI = 1.30-1.66) after adjustment for comorbidity. No deaths were observed in 128 patients under the age of 16 years. Siblings of patients did not have increased long-term mortality compared with siblings of the individuals from the comparison cohort. This study observed increased mortality due to infections (MRR = 2.57), neoplasms (MRR = 1.40), endocrine (MRR = 3.72), cardiovascular (MRR = 1.62), respiratory (MRR = 1.71), gastrointestinal (MRR = 3.35), musculoskeletal (MRR = 5.39) and genitourinary diseases (MRR = 3.37), but also due to trauma, poisoning and external causes (MRR = 2.78), alcohol abuse-related diseases (MRR = 5.59) and drug abuse-related diseases (6 vs 0 deaths, MRR not calculable). CONCLUSIONS: Patients diagnosed with spondylodiscitis have increased long-term mortality, mainly due to comorbidities, particularly substance abuse.

Espondilodiscitis: análisis de 19 casos internados en un hospital de tercer nivel / Spondylodiscitis: analiysis of 19 inpatients at a referral hospital in Rosario, Argentina

Introducción: la espondilitis representa un desafío diagnóstico, ya que el dolor lumbar, su principal manifestación clínica, constituyeun motivo de consulta muy frecuente en la práctica cotidiana y carece de especificidad. Por lo tanto, resulta indispensablemantener una elevada sospecha clínica. Objetivo: Analizar las características clínicas, analíticas, microbiológicas e imagenológicas,el tratamiento, la evolución y los factores pronósticos de pacientes internados por espondilodiscitis en el Hospital Provincial delCentenario, desde enero de 2011 a marzo de 2015, excluyéndose los casos postquirúrquicos. Resultados: Se analizaron 19 pacientescon una edad media 48±11 años, 63% varones. Se identificaron como comorbilidades: diabetes (37%), obesidad (16%), etilismo(21%), insuficiencia renal crónica en hemodiálisis (16%), HIV (11%), adicción EV (11%). Los gérmenes más frecuentes fueron losestafilococos (52%). Al ingreso el 94% presentó dolor, 73% fiebre y 36% foco neurológico. La media de tiempo de evolución desíntomas hasta ingreso fue 62±80 días (rango 4-360 días). La velocidad de eritrosedimentación fue elevada en todos los pacientes,y sólo 37% presentaban leucocitosis. La vancomicina fue el antibiótico más utilizado. El 37% de los pacientes presentaba infeccióndiseminada. La mortalidad fue del 26%. Los pacientes que tuvieron un tiempo de evolución al ingreso mayor a 25 días presentaronpeor evolución (colecciones, foco neurológico o muerte) (p<0,05). Conclusiones: en esta serie, la asociación de la consulta tardíacon la mala evolución destaca la importancia de considerar las pautas de alarma en centros de atención primaria para posibilitar undiagnóstico más temprano.

Introduction: Spondylodiscitis represents a diagnostic challenge since the main clinical manifestation, low back pain, is very frequent andnonspecific, and often impedes a timely diagnosis. Clinical suspicion is essential. Objective: to analyze the clinical, analytical, microbiological,and radiological features, as well as outcome and prognostics factors, in patients with spondylodiscitis admitted to the Hospital Provincialdel Centenario (Rosario, Argentina), from January 2011 to March 2015. Postsurgical cases were excluded. Results: Nineteen patients wereincluded. Mean age was 48±11 years, 63% were males. We identified the following comorbid diseases: diabetes (37%), obesity (16%),alcoholism (21%), hemodialysis-dependent chronic kidney disease (16%), HIV (11%), intravenous drug abuse (11%). The most frequentcausative organism was Staphylococcus sp. (52%). Upon admission 94% of patients presented pain, 73% fever, and 36% neurologicalinvolvement. The average time from the onset of symptoms to diagnosis was 62±80 days (range 4-360). The erythrocyte sedimentation ratewas raised in all the patients, and only 37% had leukocytosis. Vancomycin was the most frequently prescribed antibiotic. Disseminatedinfection was present in 37% of patients. The mortality rate was 26%. Patients with a time lag to diagnosis higher than 25 days had worseoutcome (suppurative collections, neurological involvement, or death) compared to those with earlier diagnosis (p <0.05). Conclusions:The association of late consultation with poor outcome in this study emphasizes the importance of educating the general population toencourage attendance to medical centers. Physicians in primary care settings must be trained to identify pain pattern, and incorporateclinical perspectives capable of recognizing a defined syndrome at first contact, in other to achieve a better outcome.Key words: Spondylodiscitis, comorbid conditions, diagnostic delay, outcome.

Endocarditis and spondylodiscitis associated with tunneled cuffed hemodialysis catheters: hospitalizations with poor outcomes.

INTRODUCTION: Patients undergoing chronic hemodialysis using tunneled cuffed catheters (TCCs) are at increased risk of metastatic infections, namely endocarditis and spondydodiscitis, and mortality is high in this group. The aim of this study was to determine the clinical features, causative organisms, its susceptibility and outcomes in patients hospitalized with these infections from a single center. METHODS: All consecutive patients with TCC and endocarditis and/or spondylodiscitis treated at the authors' institution between 2005 and 2011 were selected retrospectively. RESULTS: A total of 7 cases of endocarditis and 7 cases of spondylodiscitis were diagnosed. Concurrent infection was present in 1 patient. The mean age was 63.4 years, 53.8% were male, 23% had diabetes and 31% had previous immunosuppression. The average time on hemodialysis was 24 months. Those patients with endocarditis presented with fever, and 43% had previous valvular disease; mitral valve involvement was the most common. Early surgery was performed in 2 patients.Concerning spondylodiscitis, the median time from first symptom to diagnosis was 48 days. The first manifestation was back pain in 86% percent of patients, and 71% had an epidural or paraspinous abscess demonstrated by neuroimaging. One patient underwent surgical drainage of the abscess. Regarding both infections, staphylococcus aureus was the most common causative agent with a lower rate of negative blood cultures. All patients received intravenous antibiotics for a mean duration of six weeks. The mortality rate was 46%. CONCLUSIONS: A high index of suspicion is critical in the early recognition and management of both of these infections.

Increased short- and long-term mortality among patients with infectious spondylodiscitis compared with a reference population.

BACKGROUND CONTEXT: Information on short- and especially long-term mortality among patients with infectious spondylodiscitis is sparse. PURPOSE: To analyze mortality, factors associated with death, and cause-specific mortality rates among patients with infectious nonpostoperative spondylodiscitis. STUDY DESIGN: A case-cohort study. PATIENT SAMPLE: We identified all patients aged 18 years or older treated for infectious spondylodiscitis from January 1994 to May 2009 at hospitals in Funen County, Denmark. OUTCOME MEASURES: Overall and cause-specific mortality. METHODS: Mortality rates among patients were compared with rates among a reference population using Kaplan-Meier plots and mortality rate ratios (MRRs). Short-term mortality was defined as deaths within first year after admission and long-term mortality was deaths thereafter. Factors associated with death were determined. RESULTS: Among 298 identified patients, 61 (20%) died within the first year. Adjusted MRRs were 16.8 (95% confidence interval: 9.9-28.5) for 0 to 90 days; 4.2 (2.5-7.0) for 91 to 365 days; 2.2 (1.6-2.9) for 1 to 4 years; and 1.7 (1.2-2.5) for 5 to 14 years. Mortality rate ratios stratified on microbiological etiology were 8.8 (3.3-22.1) for 0 to 90 days; 1.4 (0.3-5.8) for 91 to 365 days; 3.2 (2.0-5.1) for 1 to 4 years; and 1.1 (0.5-2.4) for 5 to 14 years for unknown etiology and 24.0 (13.0-44.2) for 0 to 90 days; 6.0 (3.1-11.5) for 91 to 365 days; 1.9 (1.1-3.2) for 1 to 4 years; and 2.7 (1.5-4.7) for 5 to 14 years among Staphylococcus aureus infections. The main factors associated with short-term mortality were severe neurologic deficits at the time of admission, epidural abscess, and comorbidities. Long-term mortality seemed independent of microbiological etiology. CONCLUSIONS: Mortality remained high the first year after admission and thereafter decreased with time to a level close to the reference population. Short-term mortality was especially related to infection with abscess formation and neurologic deficits and long-term mortality was related to alcohol dependency.

[Current treatment strategies for spondylodiscitis in surgical clinics in Germany]. / Aktuelle Behandlungsstrategien der Spondylodiszitis in deutschen Akutkliniken.

BACKGROUND: Spondylodiscitis is a rare disease which is associated with high mortality. No guidelines for treatment exist and the available studies are not homogeneous. Attempts have been made in recent years to structure therapy using algorithms. Early recognition of the disease is above all important for its later outcome. Therapy takes place in not only orthopaedic/trauma surgery clinics but also in neurosurgical clinics. MATERIAL AND METHOD: We sent an online survey on this subject to orthopaedic clinics, trauma surgery and neurosurgery clinics in Germany. The aim was to ascertain current care strategies in Germany. A further objective was to elicit differences between the specialist fields. RESULTS: A total of 164 clinics responded to the survey. The response rate was 16% of the orthopaedic/trauma surgery clinics and 32% of the neurosurgical clinics. Differences between the two specialist fields can be found particularly in the use of systemic and local antibiotics, in the choice of surgical access to the thoracic spine and the lumbar spine and in post-operative imaging. In both specialist fields, patients with neurological dysfunctions are treated primarily in clinics with high case numbers. In terms of surgery, 2/3 of the responding clinics choose a one-stage operative treatment. Minimally invasive procedures and the use of cages are widespread. The participants estimate that, on the whole, a better outcome and higher patient satisfaction tend to exist after operative treatment. CONCLUSIONS: The lack of homogeneity regarding treatment strategies which is indicated here clearly shows the need for therapy guidelines as an aid to orientation. This will be a challenge for the future due to the low incidence and the situation regarding currently available studies.

Long-term mortality after Staphylococcus aureus spondylodiscitis: a Danish nationwide population-based cohort study.

OBJECTIVES: To determine the long-term mortality and the causes of death after Staphylococcus aureus spondylodiscitis. METHODS: Nationwide, population-based cohort study using national registries of adults diagnosed with non postoperative S. aureus spondylodiscitis from 1994-2009 and alive 1 year after diagnosis (n Z 313). A comparison cohort from the background population individually matched on sex and age was identified (n Z 1565). Kaplan-Meier survival curves were constructed and Poisson regression analyses used to estimate mortality rate ratios (MRR) adjusted for comorbidity. RESULTS: 88 patients (28.1%) and 267 individuals from the population-based comparison cohort (17.1%) died. Un-adjusted MRR for S. aureus spondylodiscitis patients was 1.77 (95% CI, 1.39-2.25) and 1.32 (95% CI, 1.02-1.71) after adjustment for comorbidity. We observed increased mortality due to infectious (MRR 8.57; 95% CI, 2.80-26.20), endocrine (MRR 3.57; 95%CI, 1.01-12.66), cardiovascular (MRR 1.59; 95% CI, 1.02-2.49), gastrointestinal (MRR 3.21; 95% CI, 1.178.84) and alcohol and drug abuse-related (MRR 10.71; 95% CI, 3.23-35.58) diseases. CONCLUSIONS: Patients diagnosed with S. aureus spondylodiscitis have substantially increased long-term mortality, mainly due to comorbidity. To improve survival after S. aureus spondylodiscitis these patients should be screened for comorbidity and substance abuse predisposing to the disease [corrected].

Epidemiological and clinical features of pyogenic spondylodiscitis.

Pyogenic spondylodiscitis (PS) is an uncommon but important infection, that represents 3-5% of all cases of osteomyelitis. The annual incidence in Europe has been estimated to be from 0.4 to 2.4/100,000. A has been reported, with peaks at age less than 20 years and in the group aged 50-70 years. The incidence of PS seems to be increasing in the last years as a result of the higher life expectancy of older patients with chronic debilitating diseases, the rise in the prevalence of immunosuppressed patients, intravenous drug abuse, and the increase in spinal instrumentation and surgery. PS is in most cases a hematogenous infection. Staphylococcus aureus is the most frequent causative microorganism, accounting for about one half of the cases of PS. Gram-negative rods are causative agents in 7-33% of PS cases. Coagulase-negative staphylococci (CoNS) have been reported in 5-16% of cases. Staphylococcus epidermidis is often related to post-operative infections and intracardiac device-related bacteremia. Unremitting back pain, characteristically worsening during the night, is the most common presenting symptom, followed by fever that is present in about one half of the cases. The mortality of PS ranges from 0 to 11%. In a significant number of cases, recrudescence, residual neurological defects or persistent pain may occur.

Treatment of spondylodiscitis.

PURPOSE: Pyogenic infections of the spine are relatively rare with an incidence between 1:100,000 and 1:250,000 per year, but the incidence is increasing due to increases in average life-expectancy, risk factors, and medical comorbidities. The mean time in hospital varies from 30 to 57 days and the hospital mortality is reported to be 2-17%. This article presents the relevant literature and our experience of conservative and surgical treatment of pyogenic spondylodiscitis. METHOD: We have performed a review of the relevant literature and report the results of our own research in the diagnosis and treatment of pyogenic spondylodiscitis. We present a sequential algorithm for identification of the pathogen with blood cultures, CT-guided biopsies and intraoperative tissue samples. Basic treatment principles and indications for surgery and our surgical strategies are discussed. RESULTS: Recent efforts have been directed toward early mobilisation of patients using primary stable surgical techniques that lead to a further reduction of the mortality. Currently our hospital mortality in patients with spondylodiscitis is around 2%. With modern surgical and antibiotic treatment, a relapse of spondylodiscitis is unlikely to occur. In literature the relapse rate of 0-7% has been recorded. Overall the quality of life seems to be more favourable in patients following surgical treatment of spondylodiscitis. CONCLUSION: With close clinical and radiological monitoring of patients with spondylodiscitis, conservative and surgical therapies have become more successful. When indicated, surgical stabilisation of the infected segments is mandatory for control of the disease and immediate mobilisation of the patients.

Spontaneous pyogenic spinal epidural abscess.

AIM: Spontaneous pyogenic spinal epidural abscess (SEA) is a rare condition but might be devastating and fatal. Traditional treatment is surgical decompression and antibiotics. A retrospective study was designed to assess the eff ect of clinical findings and treatment methods on the outcome. MATERIAL AND METHODS: 14 patients were reviewed (10 male, 4 female, mean age 59.14). Six dorsal, seven ventral and one dorsal with ventral SEA were observed. SEA found in thoracal (5), lumbar (4), cervical (3) regions. One patient showed both cervical and thoracal and one patient showed cervical, thoracal and lumbar involvement. All patients received minimum 3 weeks of I.V., followed by minimum 3 weeks of oral antibiotics. All patients complained of spinal pain. Ten patients presented with fever. Neurological deficit was observed in 9 cases. RESULTS: A total of 22 interventions was performed. Instrumentation was applied in 5 cases. Full recovery was achieved in 7 patients, significant improvement was observed in 5 patients. The neurological findings did not change in one patient. One mortality and one morbidity were observed. CONCLUSION: Spontaneous SEA is a rare disease but might result in catastrophic neurological deficits and fatal even with prompt treatment. Therefore, one should always keep SEA in mind if a patient presents with fever, vague and spinal pain.

Infective spondylodiscitis in patients on high-flux hemodialysis and on-line hemodiafiltration.

Infective spondylodiscitis (ISD) is a rare but potentially devastating condition in hemodialysis (HD) patients. Reports are limited especially in patients receiving high-flux HD and hemodiafiltration (HDF). In a retrospective analysis, 13 patients on our maintenance high-flux HD/HDF program were identified as having has infective spondylodiscitis over a 10-year period (1997-2006), an incidence of approximately 1 episode every 215 patient-years. The incidence was around 3 times higher in patients dialyzing with tunnelled central venous catheters (TCVC) than in those with arteriovenous fistulae. Affected patients were elderly (mean age 70 years) and had multiple comorbidities. Access problems, particularly TCVC infection, were common in the months preceding it's onset. Tunnelled central venous catheter removal during these episodes did not necessarily prevent it. Diagnosis was based on a history of back pain, raised C-reactive protein, positive blood cultures, and characteristic magnetic resonance findings. Many patients were apyrexial and had normal white cell counts. In our patients on high-flux HD/hemodiafiltration, its incidence appears comparable to that in conventional HD settings. No patients had infection with waterborne organisms. Blood cultures were positive in 77%. Gram-positive organisms predominated, particularly Staphylococcus aureus. The major route of infection was hematogenous, with the most likely source the venous access. All received antibiotics for 6 to 12 weeks or until death. Only 2 patients underwent surgical drainage. Mortality was high (46%) and predicted by the development of complications, and by pre-existing cardiovascular comorbidity. Prevention, using strategies to reduce the prevalence of bacteremia, including limiting the use of TCVC, should be an overriding aim.

Hematogenous methicillin-resistant Staphylococcus aureus spondylodiscitis.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To determine relevant demographics, clinical presentations, and outcomes of this condition. SUMMARY OF BACKGROUND DATA: This is the first study looking specifically at methicillin-resistant Staphylococcus Aureus (MRSA) spondylodiscitis. METHODS: We performed a retrospective review of patients presenting between 2000 and 2005. RESULTS: Thirteen cases were identified. The mean age was 65 years; 85% were male. All cases presented with back pain, spinal tenderness, and systemic upset. Neurologic deficit was present initially in 39%, and 8% developed neurologic deterioration during treatment. The thoracic spine (53%) was most commonly affected, followed by the lumbar (33%), thoracolumbar junction (7%), and cervical spine (7%); 16% of cases were multilevel. The white cell count, erythrocyte sedimentation rate and C-reactive protein were elevated in all cases with means of 17.3 x 10(-9)/L, 102 mm/h, and 236 mg/L, respectively. Radiologic diagnosis was established with MRI in all cases. The most common risk factors were diabetes mellitus (62%), malnourishment (54%), cirrhosis (31%), end-stage renal failure (15%), and intravenous drug use (15%). Multiple risk factors were present in 76% of cases, and only 15% had no identifiable risk factors. The main sources of sepsis were intravenous catheters (23%), urinary tract (15%), and intravenous drug use (15%). Treatment consisted of intravenous vancomycin monotherapy for a mean period of 4 weeks followed by oral combination or monotherapy antimicrobials for a mean period of 8 weeks. Operative intervention was required in 38% of cases. At 6 months, 54% of cases were clinically free of infection, 38% had died, and 8% required ongoing treatment. Neurologic deficit was present in 50% of survivors. At 1 year, 29% of survivors had MRSA bacteremia and spondylodiscitis recurrence. CONCLUSION: This is a devastating condition with high mortality and morbidity.