BACKGROUND CONTEXT: Spondylodiscitis management presents significant clinical challenges, particularly in critically ill patients, where the risks and benefits of surgical intervention must be carefully balanced. The optimal timing of surgery in this context remains a subject of debate. PURPOSE: This study aims to evaluate the effectiveness of early surgery versus delayed surgery or conservative management in critically ill patients with de novo pyogenic spondylodiscitis. STUDY DESIGN/SETTING: This is an international, multicenter retrospective cohort study involving 24 centers, primarily in Europe. PATIENT SAMPLE: The study included 192 critically ill patients (65.63% male) with a median age of 69 years, all severely affected by pyogenic spondylodiscitis characterized by an initial CRP level >200 mg/l or the presence of two out of four Systemic Inflammatory Response Syndrome criteria upon admission. OUTCOME MEASURES: The primary outcome was 30-day mortality. Secondary outcomes included length of ICU stay, length of hospital stay, and relapse rates of spondylodiscitis. METHODS: Patients were divided into three groups: early surgery (within three days of admission), delayed surgery (after three days of admission), and conservative therapy. Propensity score matching and multivariate regression analyses were performed to adjust for baseline differences and assess the impact of treatment modalities on mortality and other clinical outcomes. RESULTS: Delayed surgery was associated with significantly lower 30-day mortality (4.05%) compared to early surgery (27.85%) and conservative therapy (27.78%) (p<.001). Delayed surgery also resulted in shorter hospital stays (42.76 days) compared to conservative therapy (55.53 days) and early surgery (26.33 days) (p<.001), and shorter ICU stays (4.52 days) compared to conservative therapy (16.48 days) and early surgery (7.92 days) (p<.001). The optimal window for surgery, minimizing mortality, was identified as ten to fourteen days postadmission (p=.02). Risk factors for increased mortality included age (p<.05), multiple organ failure (p<.05), and vertebral body destruction (p<.05), whereas delayed surgery (p<.05) and the presence of an epidural abscess were associated with reduced mortality (p<.05). CONCLUSIONS: Delayed surgery, optimally between 10 to 14 days postadmission, was associated with lower mortality in critically ill spondylodiscitis patients. These findings highlight the potential benefits of considering surgical timing to improve patient outcomes.

Center for Spinal Surgery and Neurotraumatology Berufsgenossenschaftliche Unfallklinik Frankfurt am Main Germany

Clinic for Infectious and Tropical Diseases University Clinical Center of Serbia Belgrade Serbia

Clinic for Neurosurgery University Clinical Center of Serbia Belgrade Serbia

Department of Academic Neurosurgery Addenbroke's Hospital Cambridge University Hospital NHS Healthcare Trust Cambridge United Kingdom

Department of Neurosurgery and Spine Center of Eastern Switzerland Cantonal Hospital St Gallen St Gallen Switzerland

Department of Neurosurgery Athens Medical Center University of Münster Medical School European University of Cyprus Medical School Greece

Department of Neurosurgery Bethel Clinic University of Bielefeld Medical Center Bielefeld Germany

Department of Neurosurgery Cairo University Medical School and Teaching Hospitals Cairo Egypt; Security Forces Hospital Dammam Saudi Arabia

Department of Neurosurgery Christian Doppler Clinic Paracelsus Medical University Salzburg Austria

Department of Neurosurgery Clinical Center University of Sarajevo Sarajevo Bosnia and Herzegovina

Department of Neurosurgery Faculty of Medicine in Hradec Kralove University Hospital Hradec Kralove Charles University Hradec Kralove Czech Republic

Department of Neurosurgery Inselspital Bern University Hospital University of Bern Bern Switzerland

Department of Neurosurgery Jessa Hospital Hasselt Belgium

Department of Neurosurgery Medical University Innsbruck Innsbruck Austria

Department of Neurosurgery Royal Infirmary Edinburgh NHS Lothian Edinburgh United Kingdom

Department of Neurosurgery St Marien Hospital Lünen Germany

Department of Neurosurgery University Hospital of Lausitz Cottbus Germany

Department of Neurosurgery University Hospital Regensburg Regensburg Germany

Department of Neurosurgery University Hospital St Poelten St Polten Austria

Department of Neurosurgery University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Neurosurgery University Medical Center Mainz Mainz Germany

Department of Neurosurgery University Medical Center Mainz Mainz Germany; Imperial Brain and Spine Initiative Imperial College London London United Kingdom

Department of Neurosurgery Wroclaw University Hospital Wroclaw Poland

Division of Neurological Surgery Lagos State University Teaching Hospital Ikeja Lagos State Nigeria

Imperial Brain and Spine Initiative Imperial College London London United Kingdom

Neurosurgery Division Department of Neuroscience Cesena Italy

Neurosurgery Hospital Garcia de Orta Almada Portugal

Neurosurgery Unit Azienda Ospedaliera dei Colli Naples Italy

Neurosurgery Unit Department of Neuroscience University of Turin Turin Italy

Valley Baptist Medical Center Harlingen Texas USA

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