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.
- MeSH
- Anti-Bacterial Agents therapeutic use MeSH
- Length of Stay MeSH
- Discitis * therapy mortality surgery microbiology MeSH
- Conservative Treatment MeSH
- Critical Illness MeSH
- Middle Aged MeSH
- Humans MeSH
- Retrospective Studies MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Treatment Outcome MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
Bolest zad je jedním z nejběžnějších zdravotních problémů, se kterými se pacienti obracejí na lékaře. Může doprovázet svalové přetížení při špatném držení těla či degenerativní změny páteře, ale v některých případech může být signálem závažnějšího zdravotního problému, zejména je-li spojená s teplotami či jinými známkami infekce. Infekce v oblasti páteře (spondylitida, spondylodiscitida a další) jsou sice známými onemocněními, ale pro nižší frekvenci výskytu na ně často není pomýšleno, a bolest zad jako jejich hlavní symptom je mnohdy bagatelizována nebo připisována jiné etiologii. V předkládané sérii kazuistik popisujeme tři případy pacientek se spondylodiscitidou v různých částech páteře, zaměřujeme se na popis subjektivních příznaků a objektivních znaků spondylodiscitidy a popis zvoleného diagnosticko-terapeutického postupu. V rámci diagnosticky zdůrazňujeme význam magnetické rezonance jako zlatého standardu v časné diagnostice. V oblasti terapie klademe důraz na nutnost správně zvolené, a dostatečně dlouho vedené, antibiotické léčby. Naší prací chceme upozornit na to, že infekční zdroj v oblasti páteře je často v diferenciální diagnostice infekcí opomíjen, a pokud se klinický stav pacienta s infekcí nevyvíjí dle očekávaní a je u něj přítomna bolest zad, je nutné na možnost infekčního zdroje v páteři pomýšlet.
Backache or spine pain are one of the most common symptoms which lead patient to seek out for medical consult. They can be just an accompanying symptoms of muscle overload or degenerative changes of the spine, but in some cases they could signalize much more serious health problems, especially if they associated with fevers or other signs of infection. Spinal infections (spondylitis, spondylodiscitis, etc.) are well-known diseases, but due to their low incidence, they are often overlooked, and back pain as their main symptom, is often disparaged or attributed to another etiology. In the presented case series, we describe three cases of patients with spondylodiscitis in different parts of the spine. We focus on describing the subjective symptoms and objective signs of spondylodiscitis. Within the diagnostics, we emphasize the importance of magnetic resonance imaging as the gold standard to confirm the diagnosis. Within the therapy, we emphasize the necessity of correctly selected and sufficiently long-term ATB treatment. Within our work, we want to stress out the fact that the source of infection in the spine is often neglected in the differential diagnosis of infections, and if the back pain is present and the clinical condition of a patient with an infection does not develop as expected, it is necessary to consider the possibility of an infectious source in the spine.
- MeSH
- Anti-Bacterial Agents administration & dosage therapeutic use MeSH
- Back Pain * diagnosis etiology drug therapy MeSH
- Diagnosis, Differential MeSH
- Discitis * diagnosis drug therapy pathology MeSH
- Fatal Outcome MeSH
- Drug Therapy, Combination MeSH
- Comorbidity MeSH
- Humans MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Check Tag
- Humans MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
OBJECTIVE: Our research was focused to find a relation between the occurrence of spondylodiscitis and occurrence of chronic diseases. We were trying to discover some new risk factors and relations between chronic disorders in our research group. This analysis was also focused to detect factors that prolong the hospitalization of patients and worsen their prognosis. METHODS: A study was carried out involving patients with spondylodiscitis treated between 2013 and 2022. A statistical analysis expressed by several coefficients was calculated in software IBM SPSS 21. RESULTS: The study group comprised 32 (53.3%) females and 28 (46.7%) males. During the period the overall incidence of spondylodiscitis was increasing (except the year 2020 where only 2 patients were treated) with a peak in 2019. The average age of patients was 69.3 (±12.3) years, and the highest incidence was in the age group 60-69 years (n = 19, 31.7%). The most impacted vertebral region was lumbar (n = 29, 48.3%). The most prevalent associated comorbidity was some cardiovascular disorder (n = 39, 65%) followed by diabetes mellitus (DM) (n = 23, 38.3%). Genitourinary system was the most common source of primary infection (n = 22, 36.7%). Average length of stay was 34.3 (±14.5) days and surgery prolonged hospitalization period. Mortality rate was 1.7%. CONCLUSION: The results of our study are confirmed by the data of other European and non-European studies. We confirmed diabetes mellitus and hypertension as the most common non-infectious risk factors of spondylodiscitis and the presence of pathogens in genitourinary system as the most frequent source of primary infection.
- MeSH
- Chronic Disease epidemiology MeSH
- Length of Stay statistics & numerical data MeSH
- Discitis * epidemiology MeSH
- Adult MeSH
- Incidence MeSH
- Comorbidity MeSH
- Middle Aged MeSH
- Humans MeSH
- Risk Factors MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
Symptomatické neurologické komplikácie sa vyskytujú u 15-30 % pacientov s infekčnou endokarditídou. Zároveň sa u 35-60 % pacientov vyskytujú klinicky nemé mozgové embólie. Staphylococcus aureus je patogén, ktorý najčastejšie spôsobuje postihnutie nervového systému. Uvádzame prípad 67-ročného muža s infekčnou endokarditídou po stomatologickom výkone, ktorý sa prejavil ako spondylodiscitída a mnohopočetná embolizácia do mozgu, vrátane mozgového abscesu, ktorý si vyžiadal neurochirurgickú drenáž. Po 6 týždňoch liečby širokospektrálnymi antibiotikami a komplexnej podpornej terapii sme pacienta prepustili v uspokojivom somatickom a psychickom stave. Pokračuje príprava pacienta na kardiochirurgický výkon.
Symptomatic neurological complications occur in 15-30% of patients with infective endocarditis. At the same time, other clinically silent cerebral embolisms occur in 35-60% of patients. Staphylococcus aureus is the pathogen that causes nervous system involvement most frequently. We report a case of a 67-year-old man with infective endocarditis following a dental procedure that manifested as spondylodiscitis and multiple brain embolization, including a brain abscess that required drainage. After six weeks of treatment with broad-spectrum antibiotics and complex supportive therapy, we discharged the patient in a satisfactory mental and somatic condition. The preparation of the patient for cardiac surgery is ongoing.
- MeSH
- Brain Abscess diagnostic imaging etiology pathology therapy MeSH
- Discitis diagnostic imaging complications pathology MeSH
- Echocardiography, Transesophageal MeSH
- Endocarditis * diagnostic imaging drug therapy complications pathology therapy MeSH
- Tooth Extraction adverse effects MeSH
- Intracranial Embolism * diagnostic imaging complications pathology MeSH
- Humans MeSH
- Magnetic Resonance Imaging MeSH
- Mitral Valve Insufficiency diagnostic imaging etiology drug therapy MeSH
- Aged MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Aged MeSH
- Publication type
- Case Reports MeSH
PURPOSE OF THE STUDY The paper presents a monocentric retrospective study of patients treated surgically for spinal tuberculosis. Clinical and radiological results are analysed, early and late complications are recorded. The study aims to answer the following questions. 1. Can we use instrumentation to restore the stability and alignment in the infected spinal focus? 2. Should we always perform radical anterior resection of TBC lesions? 3. What is the prognosis of surgical treatment of TBC patients with neurological deficit manifestation? MATERIAL AND METHODS Between 2010 and 2020, a total of 12 patients were treated for spinal tuberculosis at our department, of whom 9 patients (5 men, 4 women) with the mean age of 47.3 years (range 29 to 83 years) underwent a surgery. A total of three patients were operated on before the final confirmation of the TBC and treatment with antituberculosis medication, four patients in the initial therapy phase and two patients in the continuous phase. Two patients only underwent a non-instrumented decompression surgery followed by external support fixation. In the other seven patients, always with spinal deformity, instrumentation was used (3 cases of isolated posterior decompression, transpedicular fixation, posterior fusion, 4 cases of anteroposterior instrumented reconstruction). In 2 cases a structural bone graft and in 2 cases an expandable titanium cage were used for anterior column reconstruction. RESULTS Of the total number of patients, altogether eight patients were assessed at 1 year after surgery (one 83-year-old patient died from heart failure 4 months after surgery). Of the remaining eight patients, three patients exhibited a neurological deficit and postoperative regression of the finding. The McCormick score improved from the preoperative mean score of 3.25 to 1.62 at 1 year after surgery (p < 0.001). The clinical VAS score regressed from 5.75 to 1.63 at 1 year after surgery (p < 0.001). Radiographic healing of the anterior fusion was achieved in all patients, both after decompression and instrumented surgery. The initial mean kyphosis of 20.36 degrees of the operated segment measured by the mCobb angle was corrected to 14.6 degrees postoperatively, with a subsequent slight deterioration to 14.86 degrees (p < 0.05). The greatest correction was achieved in patients who had undergone a two-stage surgery with anterior resection and AP reconstruction. DISCUSSION In our cohort, titanium instrumentation was used in seven of nine patients. One patient only manifested persistent tuberculosis with nonspecific bacterial flora superinfection. Revision surgery with anterior radical debridement and subsequent treatment with antituberculotic drugs healed the patient. There were four patients with major preoperative neurological deficit persisting more than 2 weeks before the final treatment with subsequent improvement in all cases. These patients were treated with anteroposterior reconstruction and anterior radical debridement. CONCLUSIONS No increased risk of recurrent infection associated with the use of spinal instrumentation was found in the study. Anterior radical debridement is performed in patients with manifested kyphotic deformity and spinal canal compression, followed by reconstruction with a structural bone graft or a titanium cage. The other patients are treated based on the principle of "optimal" debridement with or without the use of transpedicular instrumentation. If adequate spinal canal decompression and stability are achieved, neurological improvement can be anticipated even in case of a major neurological deficit. Key words: spine tuberculosis, tuberculous spondylitis, Pott's disease, anterior debridement, spine instrumentation.
- MeSH
- Lumbar Vertebrae surgery MeSH
- Decompression, Surgical MeSH
- Debridement methods MeSH
- Discitis * surgery MeSH
- Adult MeSH
- Spinal Fusion * MeSH
- Thoracic Vertebrae surgery MeSH
- Middle Aged MeSH
- Humans MeSH
- Retrospective Studies MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Titanium MeSH
- Tuberculosis, Spinal * surgery MeSH
- Treatment Outcome MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- English Abstract MeSH
- Journal Article MeSH
- Case Reports MeSH
Dysregulated systemic immune responses during infectious spondylodiscitis (IS) may impair microbial clearance and bone resorption. Therefore, the aim of the study was to examine whether circulating regulatory T cells (Tregs) are elevated during IS and whether their frequency is associated with alterations in T cells and the presence of markers of bone resorption in the blood. A total of 19 patients hospitalized with IS were enrolled in this prospective study. Blood specimens were obtained during hospitalization and 6 weeks and 3 months after discharge. Flow cytometric analysis of CD4 and CD8 T cell subsets, the percentage of Tregs and serum levels of collagen type I fragments (S-CrossLap) were performed. Out of 19 enrolled patients with IS, microbial etiology was confirmed in 15 (78.9%) patients. All patients were treated with antibiotics for a median of 42 days, and no therapy failure was observed. Next, a significant serum C-reactive protein (S-CRP) decrease during the follow-up was observed, whereas the frequencies of Tregs remained higher than those of controls at all-time points (p < 0.001). In addition, Tregs demonstrated a weak negative correlation with S-CRP and S-CrossLap levels were within the norm at all-time points. Circulating Tregs were elevated in patients with IS and this elevation persisted even after the completion of antibiotic therapy. Moreover, this elevation was not associated with treatment failure, altered T cells, or increased markers of bone resorption.
- MeSH
- Anti-Bacterial Agents therapeutic use metabolism MeSH
- Biomarkers metabolism MeSH
- Discitis * diagnosis drug therapy metabolism MeSH
- Humans MeSH
- Prospective Studies MeSH
- T-Lymphocytes, Regulatory * MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
- MeSH
- Brain Abscess * diagnosis therapy MeSH
- Discitis diagnosis therapy MeSH
- Skull pathology MeSH
- Humans MeSH
- Meningitis, Bacterial * etiology therapy MeSH
- Osteomyelitis diagnosis etiology therapy MeSH
- Spondylarthritis diagnosis therapy MeSH
- Empyema, Subdural * diagnosis therapy MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
PURPOSE OF THE STUDY The purpose of the retrospective study is to analyse a group of patients surgically treated for cervical spondylodiscitis. The first hypothesis states that the removal of infected intervertebral disc without its anterior column reconstruction in the acute phase of infection results in worse clinical and radiological evaluation of the patient. The second hypothesis defines that the use of titanium implant in anterior column reconstruction in the chronic phase of infection increases the risk of recurrent infection. MATERIAL AND METHODS The evaluated group of patients who underwent surgery includes a total of 21 patients (8 females, 13 males) with the mean age of 57.6 years. 12 patients in the acute phase of infection were treated by anterior debridement without disc space reconstruction, of whom four patients were completed by posterior instrumented fusion in the second stage. In 9 patients in the chronic phase of infection radical anterior debridement was completed by anterior titanium implant reconstruction, of whom in five patients posterior instrumented fusion was performed in the second stage. All patients were clinically evaluated by mJOA, VAS and Frankel score preoperatively, at 6 months and at 1 year postoperatively. The radiologic evaluation assessed the instrumentation failure, spinal fusion and kyphosis progression measured by sagittal Cobb angle. RESULTS The mJOA values improved from the mean preoperative value of 1.6 to 13.15 (6M) and 13.3 (1Y) postoperatively (p = 0.055). The VAS score increased from the mean value of 8.5 preoperatively to 2.15 (6M) and 1.35 (1Y) postoperatively (p < 0.001). No patient reported worse neurological finding postoperatively. The kyphosis progression measured by sagittal Cobb angle from the preoperative +6.7 decreased to +3.2 degrees at 1 year after surgery. The group of 12 patients treated in the acute phase of infection by anterior debridement without anterior column reconstruction showed worsening of kyphosis from +1.1 before surgery to +1.6 degrees at 1 year after surgery. The group of eight patients treated in the chronic phase by anterior debridement and reconstruction of the anterior column by implant changed from +15.9 before surgery to +6.1 degrees at 1 year after surgery. In two out of 12 patients with neurological deficit, the T2-weighted MRI finding of signal hyperintensity showed no improvement of the neurological deficit. DISCUSSION In the group of all operated patients, neither the worsening in the clinical evaluation using the mJOA or VAS score, nor kyphosis progression measured by Cobb angle in the sagittal plane, or failure of instrumentation in the anteroposterior procedure were reported postoperatively. In a total of nine patients operated on during the chronic phase of infection, in whom titanium implant was used to reconstruct the anterior column defect, no recurrent deep infection was observed. CONCLUSIONS In the acute phase we prefer anterior debridement with epidural abscess evacuation without anterior column reconstruction and posterior instrumented fusion in case of kyphosis progression in the second stage. In the chronic phase, radical anterior debridement with titanium implant reconstruction, eventually with posterior instrumented fusion is preferred. Key words: cervical spondylodiscitis, epidural abscess, anterior debridement, bacterial biofilm.
- MeSH
- Debridement MeSH
- Discitis * diagnostic imaging surgery MeSH
- Spinal Fusion * MeSH
- Thoracic Vertebrae MeSH
- Kyphosis * MeSH
- Middle Aged MeSH
- Humans MeSH
- Retrospective Studies MeSH
- Treatment Outcome MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- MeSH
- Spinal Cord Vascular Diseases diagnosis therapy MeSH
- Discitis diagnosis therapy MeSH
- Humans MeSH
- Myelitis diagnosis therapy MeSH
- Spinal Cord Neoplasms diagnosis therapy MeSH
- Spinal Neoplasms diagnosis therapy MeSH
- Spinal Cord Diseases * diagnosis therapy MeSH
- Spinal Cord Injuries * diagnosis therapy MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
