Current Concepts in Hematogenous Septic Spondylodiscitis
Keywords:
Spine infections; Spondylitis; Spondylodiscitis; Hematogenous SpondylitisAbstract
Hematogenous Septic spondyloDiscitis (HSD) is a rare but serious infectious disease which affects in an increasing rate immuno-compromised patients. The most common clinical symptom in HSD is a constant and increasing nocturnal axial spinal pain, while consequently different degrees of residual neurological symptoms from nerve roots and/or spinal cord may appear. The most frequent causative agent is Staphylococcus Aureus followed by the second most common to be Gram(-) bacteria. Since the disease course is chronic and clinical symptoms are not specific, surgeons should be aware that the time between the onset of the infection and final diagnosis is prolonged. MRI is mostly used to investigate HSD, however F-18 FDGPET has been recently proved to be more accurate than MRI in the detection of HSD. A delayed HSD diagnosis potentially increases morbidity and mortality while the final diagnosis is mainly based on biopsy and blood culture results.
Conservative treatment is the mainstay in cases with no residual neurological symptoms consisting of antibiotic therapy and immobilization. Surgical treatment is used in patients with neurological deficit, spinal instability or drug resistance, comprising of conventional open approaches such as anterior, posterior or combined and transcutaneous approaches. The use of metallic implants does not interfere with favorable outcome and recurrence rates. The overall mortality rate ranges from 1.5%-38%. Rates of disability of up to 31% have been reported with residual spinal dysfunction or persistent pain after recovery followed by spinal infection. The outcome of treatment is influenced by the type of infection, age, comorbidities and the degree of neurologic compromise before treatment.
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References
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32. Kehrer M, Pedersen C, Jensen TG, Hallas J, Lassen AT. Increased short- and long-term mortality among patients with infectious spondylodiscitis compared with a reference population. Spine J. 2015;15(6):1233–40
33. Rutges JP, Kempen DH, van Dijk M, OnerFC. Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review. Eur Spine J 2016;25(4):983–992
34. O’Daly, JB; Morris, FS, O’Rourke, KS.Long-term Functional Outcome in Pyogenic Spinal Infection. Spine 2008; 33: pp E246–E253
35. McHenry M, Easley KA, Locker GA. Vertebral osteomyelitis:long-term outcome for 253 patients from 7 Cleveland-area hospitals.Clin Infect Dis 2002;34:1342–50
36. Solis Garcia delPozo J, Vives Soto M, Solera J. Vertebral osteomyelitis: long-term disability assessment and prognostic factors. J Infect 2007;54:129–34
2. Nickerson EK, Sinha R. Vertebral osteomyelitis in adults: an update. Br Med Bull 2016;117:121–138
3. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenouspyogenic spinal infections and their surgical management.Spine 2000;25(13):1668–79
4. Cottle L, Riordan T. Infectious spondylodiscitis. J Infect.2008;56:401–412
5. Hempelmann RG, Mater E, Schon R. Septic hematogenous lumbar spondylodiscitis in elderly patients with multiple risk factors:efficacy of posterior stabilization and interbody fusion with iliac crest bone graft. Eur Spine J. 2010;19:1720–1727
6. Aagard T, Roed C, Dragsted C, Skinhøj P. Microbiological and therapeutic challenges in infectious spondylodiscitis: a cohort study of 100 cases, 2006–2011. Scand J Infect Dis. 2013;45:417–424
7. Pigrau, C, Rodrıguez-Pardo, D; Fernandez-Hidalgo,N,Moretó L, Pellise F, Larrosa MN, et al. Health Care Associated Hematogenous Pyogenic Vertebral Osteomyelitis. A Severe and Potentially Preventable Infectious Disease.Medicine 2015; 94: 3
8. Cheng AG, DeDent AC, Schneewind O, Missiakas D. A play in four acts:Staphylococcus aureus abscess formation. Trends Microbiol. 2011;19(5):225–32
9. Cheng AG, Kim HK, Burts ML, Krausz T, Schneewind O, Missiakas DM. Genetic requirements for Staphylococcus aureus abscess formation and persistence in host tissues. FASEB J. 2009;23(10):3393–404
10. Al-Nammari SS, Lucas JD, Lam KS. Hematogenous methicillin resistant Staphylococcus aureus spondylodiscitis. Spine.2007;32:2480–2486
11. Graham SM, Fishlock A, Millner P, Sandoe J. The management gram-negative bacterial haematogenous vertebral osteomyelitis: a case series of diagnosis,treatment and therapeutic outcomes. EurSpine J. 2013;22(8):1845–53
12. Sakkas,IL, Davas,ME, Kapsalaki, E, Boulbou M, Makaritsis K, Alexiou Iet al. Hematogenous Spinal Infection in Central Greece Spine 2009; 34: E513–E518
13. Korovessis P, Vardakastanis K, Fennema P Syrimbeis V . Mesh cage for treatment of hematogenous spondylitis and spondylodiskitis. How safe and successful is its use in acute and chronic complicated cases? A systematic review of literature over a decade. Eur J Orthop Surg Traumatol. 2016;26(7):753-61
14. Park KH, Cho OH, Jung M, Suk KS, Lee JH, Park JS, et al. Clinical characteristics and outcomes of hematogenous vertebral osteomyelitis caused by gram-negative bacteria. J Infect. 2014;69(1):42–50
15. Ledermann HP, Schweitzer ME, Morrison WB, Carrino JA.MR imagingfindings in spinal infections: rules or myths? Radiology 2003;228:506–514
16. Dunbar JA, Sandoe JA, Rao AS, Crimmins DW, Baig W, Rankine JJ. The MRI appearances of early vertebral osteomyelitis and discitis. ClinRadiol 2010;65:974–81
17. Carragee EJ. The clinical use of magnetic resonance imaging in pyogenic vertebral osteomyelitis. Spine 1997;22:780–5
18. Seong-Jang Kim, Kyoungjune Pak, Keunyoung Kim, Jung Sub Lee Comparing the Diagnostic Accuracies of F-18 Fluorodeoxyglucose Positron Emission Tomography and Magnetic Resonance Imaging for the Detection of Spondylodiscitis.A Meta-analysis. Spine 2018; 44 E414–E422
19. Zimmerli W. Clinical practice.Vertebral Osteomyelitis. N Engl J Med. 2010;362(11):1022–9
20. Bernard L, Dinh A, Ghout I, Simo D, Zeller V, Issartel B, , et al. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomized, controlled trial. Lancet. 2015;385:875–82
21. Walters R, Vernon-Roberts B, Fraser R, Moore R. Therapeutic use of cephazolin to prevent complications of spine surgery. Inflammopharmacology 2006;14(3–4):138–43
22. Al-Nammari SS, Lucas JD, Lam KS. Hematogenous methicillin-resistant Staphylococcus aureus spondylodiscitis. Spine 2007;32(22):2480–6
23. Khan IA, Vaccaro AR, Zlotolow DA. Management of vertebral diskitis and osteomyelitis. Orthopedics. 1999;22:1668–1679
24. Shiban E, Janssen I, Wostrack M, Krieg SM, Horanin M, Stoffel M, et al. Spondylodiscitis by drug-multiresistant bacteria: a single-center experience of 25 cases. Spine J. 2014;14(12):2826–34
25. Fukuta S, Miyamoto K, Masuda T. Two-stage (posterior andanterior) surgical treatment using posterior spinal instrumentation forpyogenic and tuberculoticpondylitis. Spine. 2003;28:e302–e308
26. Oh HS, Kim JS, Lee SH,Liu WC, Hong SW. Comparison between the accuracy ofpercutaneous and open pedicle screw fixations in lumbosacral fusion.Spine J. 2013;13:1751–1757
27. Lin, Y, Li, F, Chen, W, Zeng, H, Chen A, and Xiong W. Single-level lumbar pyogenic spondylodiscitis treated with mini-open anterior debridement and fusion in combination with posterior percutaneous fixation via a modified anterior lumbar interbody fusion approach. J Neurosurg Spine 23:747–753, 2015
28. Korovessis P, Repantis T, Iliopoulos P, Hadjipavlou A. Beneficial influence of titanium mesh cage on infection healing and spinal reconstruction in hematogenous septic spondylitis: A retrospective analysis of surgical outcome and twenty-five consecutive cases and review of literature. Spine 2009;33:759–767
29. Pee YH, Park JD, Choi YG, Lee SH. Anterior debridement and fusionfollowed by posterior pedicle screw fixation in pyogenic spondylodiscitis:autologous iliac bone strut versus cage. J Neurosurg Spine.2008;8:405–412
30. Bydon MD; De la Garza-Ramos; R, Macki M,NaumannM; SciubbaDM; WolinskyJP: Spinal instrumentation in patients with primary spinal infections does not lead to greater recurrent infection rates: an analysis of 118 cases. World Neurosurg 2004;82:e807–e814
31. Taylor, GD, Buchholz,LA, , Sure, RD, Buell, JT, Nguyen,HJ, Ching-Jen Chen. Presentation and Outcomes After Medical and Surgical Treatment Versus Medical Treatment Alone of Spontaneous Infectious Spondylodiscitis: A Systematic Literature Review and Meta-Analysis. Global Spine Journal 2018; 8(4S) 49S-58S
32. Kehrer M, Pedersen C, Jensen TG, Hallas J, Lassen AT. Increased short- and long-term mortality among patients with infectious spondylodiscitis compared with a reference population. Spine J. 2015;15(6):1233–40
33. Rutges JP, Kempen DH, van Dijk M, OnerFC. Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review. Eur Spine J 2016;25(4):983–992
34. O’Daly, JB; Morris, FS, O’Rourke, KS.Long-term Functional Outcome in Pyogenic Spinal Infection. Spine 2008; 33: pp E246–E253
35. McHenry M, Easley KA, Locker GA. Vertebral osteomyelitis:long-term outcome for 253 patients from 7 Cleveland-area hospitals.Clin Infect Dis 2002;34:1342–50
36. Solis Garcia delPozo J, Vives Soto M, Solera J. Vertebral osteomyelitis: long-term disability assessment and prognostic factors. J Infect 2007;54:129–34
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Published
2021-04-26
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