Surgical intervention in patients with spondylodiscitis

Predicting the need for surgical intervention in patients with spondylodiscitis: the Brighton Spondylodiscitis Score (BSDS)

April 2019

European Spine Journal 28(11)
DOI:10.1007/s00586-018-5775-x
Project: A scoring system for operative management of spondylodiscitis

Authors:
Nageswary Appalanaidu
Roozbeh Shafafy
Kit Brogan
Lambros Giuseppe Morassi
Sherief Elsayed
Christopher Gee
Shuaib Karmani

Predicting the need for surgical intervention in patients with spondylodiscitis: the Brighton Spondylodiscitis Score (BSDS)

Predicting the need for surgical

intervention in patients with spondylodiscitis: the Brighton Spondylodiscitis Score (BSDS)

Nageswary Appalanaidu, Roozbeh Shafafy, Christopher Gee, Kit Brogan, Shuaib Karmani, Giuseppe Morassi & Sherief Elsayed

European Spine Journal

ISSN 0940-6719

Eur Spine J

DOI 10.1007/s00586-018-5775-x

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1 3

European Spine Journal https://doi.org/10.1007/s00586-018-5775-x

ORIGINAL ARTICLE

Predicting the need for surgical intervention in patients

with spondylodiscitis: the Brighton Spondylodiscitis Score (BSDS)

Nageswary Appalanaidu1 · Roozbeh Shafafy1 · Christopher Gee1 · Kit Brogan1 · Shuaib Karmani1 · Giuseppe Morassi1 · Sherief Elsayed1

Received: 18 April 2018 / Revised: 3 September 2018 / Accepted: 24 September 2018

Abstract‌

Purpose Spondylodiscitis represents a condition with significant heterogeneity. A significant proportion of patients are managed without surgical intervention, but there remains a group where surgery is mandated. The aim of our study was to create a scoring system to guide clinicians as to which patients with spondylodiscitis may require surgery.

Methods A retrospective analysis of patients presenting to our institution with a diagnosis of spondylodiscitis between 2005 and 2014 was performed. Data for 35 variables, characterised as potential risk factors for requiring surgical treatment of spondylodiscitis, were collected. Logistic regression analysis was performed to evaluate the predictability of each. A prediction model was constructed, and the model was externally validated using a second series of patients from 2014 to 2015 meeting the same standards as the first population. The predicted odds were calculated for every patient in the data set. Receiver operating characteristic (ROC) curves were created, and the area under curve (AUC) was determined.

Results Sixty-five patients were identified. Surgery was deemed necessary in 21 patients. Six predictors: distant site infection, medical comorbidities, the immunocompromised patient, MRI findings, anatomical location and neurology, were found to be the most consistent risk factors for surgical intervention. An internally validated scoring system with an AUC of 0.83 and an Akaike information criterion (AIC) of 115.2 was developed. External validation using a further 20 patients showed an AUC of 0.71 at 95% confidence interval of 0.50–0.88.

Conclusions A new scoring system has been developed which can help guide clinicians as to when surgical intervention may be required. Further prospective analyses are required to validate this proposed scoring system.

Graphical abstract These slides can be retrieved under Electronic Supplementary Material.

Key points

Take Home Messages

Predict
Spondylodiscitis
Treatment

No clear guidance exists as to which patients with spondylodiscitis require surgical treatment.
A retrospective analysis of patients with spondylodiscitis revealed six predictors of surgical intervention.
These predictors were used to create an internally and externally validated scoring system to guide clinicians as to when surgical intervention may be required in the treatment of spondylodiscitis.

Appalanaidu N, Shafafy R, Gee C, Brogan K, Karmani S, Morassi G, Elsayed S (2018) Predicting the need for surgical intervention in patients with Spondylodiscitis – The Brighton Spondylodiscitis Score (BSDS). Eur Spine J;

Keywords Predict · Spondylodiscitis · Treatment

Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00586-018-5775-x) contains supplementary material, which is available to authorized users.

Extended author information available on the last page of the article

Introduction

Spondylodiscitis describes any infection of the intervertebral disc and or adjacent vertebra and is a potentially life-threatening illness with a mortality rate of 2–20% [1, 2]. It may affect the vertebral bodies, intervertebral discs or posterior elements of the spine including adjacent tissues (e.g. paravertebral and psoas muscles) and spinal canal (e.g. epidural abscesses) [3–5].

The prevalence of spondylodiscitis is on the rise, with an estimated 0.4–2.4 per 100,000 individuals affected in the western population [2, 6]. This may be in part due to a rise in the number of individuals vulnerable to infections (e.g. elderly or immunocompromised) or related to other methods of invasive treatments such as intravenous catheter use for example [2, 3]. Advances in diagnostic imaging may have also led to a previously under-recognised condition being diagnosed more often [4, 7]. The risk factors for spondylodiscitis are: an immunocompromised host, diabetes, advanced age, long-term corticosteroid therapy, renal failure, previous spinal surgery, endocarditis and intravenous drug use [7, 8].

When spondylodiscitis occurs as a complication of distant site infection, bacteraemia or sepsis must occur. Patients may therefore present with a wide range of symptoms, which may or may not be dominated by the primary infective focus and, as a result, a delay in diagnosis is common [9].

The optimum treatment of spondylodiscitis is a challenge, partly due to a lack of a clear consensus on the role of operative treatment. Often the decision is based on clinician preference [10] although medical management frequently forms the basis for treatment, be it alone or in combination with surgery. It normally includes an extended course of antibiotics with optional orthoses and/ or bed rest [3] although, as with most musculoskeletal infections, there is debate regarding the optimum route and duration of antibiotic treatment. Some patients may require biopsies when clinical evaluation is unsatisfactory, there is suspicion of an atypical bacteria and if no microorganism has been isolated elsewhere. Failure of conservative management, neural compression, and spinal instability or deformity are the currently accepted indications for surgical intervention [11]. The surgical options are dependent on the site of infection and the indication for surgery. Options include anterior debridement and stabilisation (ideal approach as the anterior spine is usually involved in the pathogenesis of spondylodiscitis [12]); combined anterior–posterior methods; transpedicular curettage and drainage; as well as posterior stabilisation [10, 11].

The lack of evidence to direct surgeons as to which

patients require surgery has led to inconsistencies in

treatment [1, 2, 7]. Sobottke et al. [10] indicated that when compared to conservative and/or medical management, surgical intervention in patients with uncomplicated spondylodiscitis ensures faster mobilisation and recovery as well as improved short-term quality of life. A recent study by de Graeff et al. [13] identified that diabetes, epidural abscess or concurrent other osteomyelitis were independent factors associated with failure of antibiotic treatment of spondylodiscitis. However, at present, no study has classified a set of predictors into a scoring system to aid the surgeon as which patients with spondylodiscitis would benefit from either medical or surgical management [2, 7]

In this study we aim to:

Evaluate the results of the management of spondylodiscitis in our institution and use the data from these patients to identify risk factors for requiring surgery.
To produce a scoring system to stratify the risk of patients needing surgery and to then validate the score on a further group of patients.
To compare outcomes in those treated operatively and non-operatively with the null hypothesis that surgical intervention does not improve outcome.

Materials & methods

A literature review was performed to identify potential risk factors for spondylodiscitis and for requiring surgical intervention. These risk factors were then used as the basis for data collection.

A retrospective review of 65 patients with spondylodiscitis treated between 2005 and 2014 at our institution was performed. Patients were identified initially through MRI results and then confirmation through a review of the casenotes, where the treating clinician made a diagnosis of spondylodiscitis. All adult patients who presented with acute bacterial spondylodiscitis were included. Paediatric patients, those with tuberculous or fungal infections and those with post-surgical infections were excluded. Patient and surgical data was then collected using the potential risk factors identified for requiring surgery.

Logistic regression was initially performed onto the training set of data as the pioneer form of modelling. Through this method, the response (i.e. status of surgical intervention) as the outcome of interest was determined and all the other available predictors (i.e. gender, age, health status etc.) were labelled as the original factors to build the model. To produce an exclusive prediction model, a backward (Wald) stepwise predictor was chosen and the process was repeated at a default of 1000 times for each of the data sets (boot-strap). With this, a series of predictive models was produced by classifying the predictors on the number of stages they

occur in the 1000 “bootstrap” resamples. The final prediction model was built based on the previously classified list of predictors which were sequentially added, and the representation with the lowest Akaike information criterion (AIC) was chosen as the final model. The model was internally validated by determining the area under the curve (AUC) using multiple cutoff values on the expected probability of the scoring system.

In order to validate the model externally, further 20 patients treated from 2014 to 2015 from the same organisation (BSUH) were retrospectively reviewed. This group was labelled as the “validation group”, and the same inclusion criteria for the initial analysis were used. The probability that signified chances to undergo surgical intervention was produced for each of the patients from the validation group. Then, specificity, sensitivity, negative predictive value (NPV) and positive predictive value (PPV) were determined. Depending on the “probability threshold”, these calculated figures were able to alter the predicted outcome of a particular patient. For example, patients with a probability ≤ 0.5 will obtain medical management only, whereas those > 0.5 will undergo surgical intervention as part of their treatment.

Data analysis of the “validation group” was performed to externally validate the prediction model. Based on the set of data obtained, categorical groups were made to facilitate the analysis via SPSS. For example, anatomical locations were divided into cervical, thoracolumbar and lumbosacral. Therefore, an infection at C6-C7 was labelled as cervical. Microbial cultures were clustered into non-MRSA and polymicrobial groups with MRSA/MRSA alone groups to simplify statistical analysis. A pre-analysis briefing was constructed to predict the consistency and validity of the groups. The constructed predictive model in the initial analysis was used on the “validation group” to evaluate predicted probabilities. The “Bootstrap approach” was used, and this method was reiterated at a default of 1000 to form the receiver operating curves (ROC) and to evaluate the AUCs using the resamples from the validation data.

Results

Table 1 depicts the results used to construct the predictive model for internal validation. Nearly half of patients presented with some degree of neurological compromise, and 35.4% demonstrated vertebral collapse > 30% anterior vertebral height. Only half of patients presented with a fever and in 25% of patients multiple levels were affected. 32% of patients required surgical intervention with the most frequent indication being abscess drainage. 71% of patients were independently mobile prior to the onset of symptoms with 55% maintaining independent mobilisation post-operatively. A third of patients had an improvement

in their neurology from initial presentation with over half of the patients requiring rehabilitation after discharge from hospital. The average time to diagnosis from presentation was 4 days and on average patients required an inpatient stay of 35 days. In 32% of patients the infective organism could not be identified and in this group the diagnosis was made on a clinical and radiological basis. 23% of patients had either a UTI, pneumonia or endocarditis and 30% presented with sepsis/bacteraemia.

One or more comorbidities was present in 79% of patients. Diabetes was the most common medical risk factor at 83%, with 35.4% immunocompromised from steroid use, HIV, dialysis or previous organ transplant.

Staphylococcus remained the most common organism (27.7%) followed by coagulase negative staphylococci, gram negative bacilli, polymicrobial cultures and others.

The majority of patients were treated with a 6-week course of antibiotics (90%) with blood results used to monitor response.

Table 2 depicts the logistic regression analysis used to identify the most crucial variables that contributed to increased probability of surgical intervention. Using ‘boot-strap’ prediction techniques via SPSS, seven grouped predictors were identified to be the most consistent variables to predict the need for surgical intervention.

These risk factors were then analysed as predictors, which are shown in Table 3. The higher the value of the coefficient, the more likely a risk factor is to predict surgical intervention in the group. The p value on the other hand implies the impact of each variable to the model entirely. It is said that the higher the p value, the lower its relative significance. Using this analysis, a scoring system was produced (Table 4). The internal validation of this system produced an AIC of 115.20 and an AUC of 0.83. This scoring system was then externally validated using the further 20 patients from 2014 to 2015 with an AUC of 0.71 (95% CI, 0.50–0.88).

Various probability cutoff points were applied to determine the specificity, sensitivity, NPV and PPV. The threshold figures were fixed at a value of 0.35. At this limit value, reliable results were identified as follows: Specificity—0.52; sensitivity—0.75; NPV—0.75; PPV—0.61.

Treatments outcomes of patients categorised as low, medium and high risk by the BSDS are demonstrated in Table 5. Out of 49 patients deemed low risk, 5 required subsequent surgery. Of the 6 patients deemed high risk, all six had surgical intervention.

Outcomes between the two sets of patients in the internal validation group of 65 were assessed and are outlined in Table 6. The results demonstrate more favourable neurological and mobility outcomes in the surgical group. These results also demonstrate a trend towards a quicker improvement in CRP and shorter length of stay although this is not significant.

Variables	Responses	Frequency	Percentage	Mean	Range	Standard deviation
Age (years) Gender	Years Male	38	58.5	69.22	22–93	13.331
	Female	27	41.5
Neurologic status	Intact	33	50.8
	Deficit	32	49.2
	Motor	22	33.8
	Sensory	5	7.7
	Complete	5	7.7
MRI findings	Vertebral collapse	23	35.4
	Abscess formation	16	24.6
	Non-specific fluid collection	14	21.5
	Not specified	12	18.5
Fever	Yes	33	50.8
	No	32	49.2
Levels affected	Single	49	75.4
	Multiple	16	24.6
Affected spinal column	Cervical	13	20.0
	Thoracolumbar	36	55.4
	Lumbar/Sacral	6	9.2
	Widespread	10	15.4
Surgery	Yes	21	32.3
	Abscess drainage	7	10.8
	Decompression	5	7.7
	Stabilisation	4	6.2
	Laminectomy	3	4.6
	Combined	2	3.0
	No	44	67.7
Mobility	Before surgery	46	70.8
	Non-independent After surgery	19	29.2
	Independent	36	55.4
	Non-independent	29	44.6
Improvement in neurology	No changes	32	49.2
	Improved	22	33.8
	Worsening	10	17.0
Post Op complication	DVT	3	4.6
	Infection	7	10.8
	Failure/relapse	4	6.2
	Further surgery	4	6.2
Rehab	Yes	37	56.9
Time to diagnosis (days)	No	28	43.1	4.09	2–30	10.130
Admission duration (days)				35.08	5–130	24.989

Table 1 Results of retrospective casenote analysis of patients presenting with spondylodiscitis

Independent

Table 1 (continued)
Variables	Responses	Frequency	Percentage	Mean	Range	Standard deviation
Risk factors	Diabetes
	IDDM	13	20.0
	NIDDM	39	60.0
	Diet controlled DM	2	3.1
	Non-diabetic	11	16.9
	Malignancy	14	21.5
	Immunocompromised
	LT steroid therapy	3	4.6
	Dialysis	14	21.5
	Transplant	5	7.7
	HIV IV Drug users	1	1.5
	Current	3	4.6
	Ex-IVDU	3	4.6
	Non-IVDU	59	90.8
	Smoking
	Current	9	13.8
	Ex-smoker	25	38.5
	Non-smoker	31	47.7
Microbial cultures	Positive culture	44	67.7
	Gram positive
	Gram negative or polymicro-	23	35.4
	Polymicrobial with	11	16.9
	MRSA or MRSA alone	10	15.4
	Negative culture	21	32.3
Distant site infection	Present	35	53.8
	UTI/pneumonia	10	15.3
	Endocarditis	5	7.7
	Sepsis/Bacteraemia	20	30.8
	Absent	30	46.2

bial w/out MRSA

Discussion

Managing spondylodiscitis

With an increasingly comorbid and ageing population, spondylodiscitis will become more common and a clear understanding of which patients require surgery is essential. Surgery may include abscess drainage, debridement and stabilisation which may be either anterior or posterior or a combination of all of the above. This study has demonstrated a significantly superior neurological and functional outcome in the surgical group with a trend towards a quicker improvement in CRP and a shorter length of stay. Rossbach et al. [14] have also demonstrated favourable outcomes with surgery. Some evidence suggests prolonged periods of preoperative immobility in the elderly population are associated with greater risk of mortality [15]. The approach and

choice of surgery are still up for debate, and a review of the literature pertaining to surgical options is summarised in Table 7 [16–23].

Understanding the microbiology of discitis is important. In this study Staphylococcus Aureus remained the most common organism. In the elderly with urinary tract infections E Coli infections may be seen, in intravenous drug users Pseu-domonas Aeruginosa was common, and in patients with diabetes there was an increased prevalence of Group B haemo-lytic Streptococcus. Whilst these were the most common organisms identified in this study, in nearly a third of cases the organism could not be identified. Recent evidence suggests that a microbiological diagnosis is the main predictive factor for a successful treatment outcome [24]. Close liaison with microbiology services, together with an understanding of the common organisms involved, is recommended to guide empirical treatment when no organism is identified.

probability of surgical	Age	5 years incremental	1.058	0.102	0.337	0.030
intervention	Gender	Male vs Female	2.576	0.601	8.557	0.177
	Neurology	Deficit vs Intact	2.140	0.822	5.454	0.078
	MRI findings	Vertebral collapse Abscess formation Non-specific fluid collection	1.867 3.947 0.739	0.520 0.273 0.201	6.485 2.595	0.657
	Levels affected	Not specified Single vs multiple	0.476 1.430	0.052 0.199	4.401 2.897	0.641
	Affected location	Thoracolumbar vs Cervical Lumbosacral vs Cervical	1.750 1.780	0.389 0.468	7.898	0.690
	Medical co morbidities	Widespread vs Cervical Diabetes vs none IVDU vs none	1.003 4.346 1.964	0.221 1.269 0.781	5.998 11.883	0.109
	Immunocompromised	Smoking vs none Dialysis vs none Cancer vs none Steroid therapy vs none	1.342 2.010 0.711 0.611	0.269 0.018 0.189 0.426	2.421 3.422 2.230	0.109
	Microbial cultures	Transplant vs none Gram negative vs gram positive (non-MRSA) alone vs gram positive (non-	0.310 0.531 2.709	0.233 0.188 0.801	2.033 1.856	0.034
	Distant site infection	Present vs none Pneumonia/UTI vs none Endocarditis alone vs none Sepsis alone vs none	1.072 2.869 4.999 5.856	0.761 0.796 1.234 1.673	1.005 20.239	0.037
	CI confidence interval
Table 3 Analysis of risk factors	Predictors	Subcategories		Coefficient		p value
influence of predictors	Distant site infection Medical comorbidities	None UTI/pneumonia Endocarditis Sepsis Diabetes mellitus		– 1.700 1.080 2.133		0.037 0.109

Test Factors	Outcome	Estimated	Lower CI	Upper CI	p value
		odds ratio

Table 2 Logistic regression analysis to identify variables associated with increased

5.476

6.789

2.909

1.123

Polymicrobial with MRSA or MRSA MRSA)

8.102

10.346

20.5

for surgical intervention and

IVDU

Others

Immunocompromised Metastatic cancers

Dialysis

Long term steroid therapy HIV positive

MRI findings Vertebral collapse Abscess formation

Non-specific fluid collection Not specified

Spine location Cervical Thoracolumbar Lumbosacral Widespread

– 0.301

1.555

0.888

0.551

1.988

0.111

– 0.133

0.122

1.678

– 0.223

– 0.422

– 1.511

1.066

0.881

– 1.001

0.106

0.257

0.490

Neurology on presentation

None Motor Sensory

Complete deficit

– 1.444

0.185

0.189

0.102

0.201

Microbiology Gram positive

Gram negative or polymicrobial (non-MRSA) Polymicrobial with MRSA or MRSA alone

– 1.400

– 1.883

1.987

0.234

Table 4 Brighton Spondylodiscitis Score (BSDS) Table 5 Treatment outcomes of patients categorised as low, moderate‌

Predictors Relative

Score

Risk of requiring surgery

and high risk

Total Required surgical intervention

Distant site infection 1

None 3

UTI/pneumonia 5

Endocarditis 6

Sepsis

Comorbidities 1

None 3

IVDU 5

Diabetes mellitus

Immunocompromised 1

None 4

Metastatic cancers 6

Dialysis

MRI Findings 1

None 2

Non-specific fluid collection 4

Vertebral collapse 5

Abscess formation

Anatomical location 1

Cervical 3

Lumbosacral 5

Thoracolumbar

Neurology on presentation 1

None 2

Motor/sensory 3

Complete

Low: 7–14

Moderate: 15–20

High: 21–33

Low risk 49 n = 5

Abscess drainage (5)

Moderate risk 10 n = 10

Abscess drainage (2)

Decompression (6)

Stabilisation (2)

High risk 6 n = 6

Abscess drainage & stabilisation (2) Decompression (2)

Stabilisation (2)

symptoms or normalisation of inflammatory markers (CRP/ ESR) with close monitoring of these inflammatory markers after cessation of antibiotic treatment.

In our study advanced age alone was not identified as a risk factor for surgical intervention in spondylodiscitis. This may be due to a trend towards conservative management in older patients or perhaps that age alone does not determine outcome. In their retrospective study of tubercular spondylodiscitis, Shetty et al. [26] felt that the disease process was more severe in elderly patients. Further analysis of their study demonstrates that a significant portion of patients (55%) had limited mobility as well as multiple comorbidities (5 or more in one fifth of patients). Factors such as the presence of comorbidities and mobility may act as surrogate

Relapse is potentially problematic in spondylodiscitis. Understandably there is a concern for recurrent infection when implants are used; however, in this study there was no difference in relapse from infection between those treated operatively or with antibiotics alone. However, studies have shown that ≤ 4 weeks antibiotic treatment is a risk factor for failure of treatment [25]. Patients with more severe vertebral destruction treated with surgery have also been identified as a group at risk of recurrence, but this may represent a more severe or neglected disease processes. Typically medical treatment is advised to continue until resolution of

markers of frailty, be a more reliable guide to patient condition and a more important factor in the disease prognosis rather than age alone. A recent large study by Pola et al.

[24] did not identify age as a risk factor for poor outcome in spondylodiscitis. There is, however, evidence to suggest that poor pre-operative mobility is a risk factor for mortality in elderly patients undergoing surgery for tubercular spondylodiscitis [15] and frailty scoring may be a useful tool in predicting outcome in these patients [27].

Medical comorbidities remain significant risk factors for spondylodiscitis. Diabetes, malignancy,

Table 6 Analysis of outcome comparing treatment with antibiotics only and antibiotics with surgery

Outcomes	Antibiotics only	Antibiotics and surgical intervention	P value
Neurology Favourable	16 28	17	p = 0.031
Unfavourable Blood test (mean levels) CRP (presentation) CRP (1/52)	120.85 74.08 24.99	79.97 17.87	p > 0.05
CRP (6/52) Mobility Improved Deteriorated	16 8 20	17 2	p = 0.029
No changes Relapse/failure	20	5	p > 0.05
Admission duration (mean days)	39.1	30.8	p > 0.05
Rehab (patients)	23	26	p > 0.05

61.45

immune-compromise from steroids, HIV, dialysis or transplant are all risk factors. Optimising the chronic management of these conditions may have an effect on the incidence of spondylodiscitis and having a lower threshold for spinal MRI in these ‘at risk groups’ who present with pyrexia of unknown origin or with back pain is advised. Akiyama et al.

[28] also identified that mortality rates in these patients were comparatively high compared to those without significant comorbidities.

The site of the infection is an important consideration when managing spondylodiscitis. Thoracolumbar spondylodiscitis is most common and this likely relates to Batsons venous plexus as a conduit for haematogenous innoculation. However, cervical spondylodiscitis occurred in 20% of our patients and in 15% there was a more widespread infection. It was also observed that thoracolumbar spondylodiscitis more commonly required surgery, which may be related to the presence of instability.

Scoring system

The scoring system presented here is the first of its kind to attempt to aid treating clinicians in identifying patients who may require surgical intervention for spondylodiscitis. The results from our study demonstrate that the scoring system has reasonable clinical value with an internal validation AIC and AUC of 115.20 and 0.83, respectively.

There are, however, weaknesses to our study. As data were collected retrospectively and over a long time period where there were no guidelines in place, treatment will have

been variable and based on clinical expertise. This allows for significant variations in care. The scoring system has again been validated based on a retrospective analysis without standardised care. However, this study is the first we are aware of to attempt to provide a scoring system to stratify the risk of surgery and we would suggest further prospective studies to further validate or modify the scoring system.

Our retrospective analysis has also demonstrated an improvement in outcomes with surgery, albeit in a relatively small group of patients treated over a long period of time. Given the suggestion that surgery may improve length of stay and time to normalisation of inflammatory markers without significantly higher rates of relapse, randomised studies are warranted to assess whether early surgical debridement and stabilisation should have a greater role in managing these patients in the future.

Conclusions

The Brighton Spondylodiscitis Score (BSDS) provides a framework to allow treating clinicians to understand which patients with spondylodiscitis may require surgery. A multidisciplinary approach is advised in these patients to ensure optimum outcomes. Future studies are required to further validate this scoring system. Randomised controlled trials are advised to assess whether surgery should have a greater role and can improve outcomes in these patients.

Table 7 Summary of literature pertaining to surgical management of spondylodiscitis

Author/publication year/type of study

Surgical approach Positive microbial cultures (%)

Period of antibiotic treatment Further surgi-

cal intervention

Failure/relapse Mortal-

ity rate (%)

Conclusion of article

Linhardt 2007 [16] (RCT)

Ventral spondylodesis N = 12

Ventrodorsal spondylodesis N = 10

ND 23.8 weeks

24.1 weeks

0% Failure

0% 0%

Relapse 9%

Failure 0%

Relapse 0%

25%

10%

Follow-up: 5.4 years

Patients who underwent ventral spondylodesis only felt much better and the area of spinal fusion was less painful compared to those with ventrodorsal fusion

Author’s personal copy

European Spine Journal

Ozturk 2007 [17] (RCos)

Simultaneous anterior

and

posterior surgery

N = 29

Separate anterior and posterior surgery

N = 27

99 IV: 6 weeks

Oral: 3 months

ND Failure ND 0% ND

Relapse ND Failure

Relapse ND

Follow-up: 6.5 years

Simultaneous anterior and posterior surgery was a beneficial substitute method. It resulted fewer complications, shorter operative time and reduced blood loss

Pee

2008 [18] (RCoS)

Anterior strut followed by pedicle screw

fixation

N = 37

Anterior cage followed by pedicle screw fixation

N = 23

45 IV: 6 weeks (min) Oral: 6 Weeks (min)

8.0%

4.1%

Failure ND ND

Relapse ND ND Failure ND

Relapse ND

Follow-up: 35.8 months

Anterior spinal debridement and fusion of cage followed by fixation of pedicle screw may be successful

Si 2013 [19] (PCoS)

Anterior debridement and spondylodesis

N = 11

Dorsal

spondylodesis and anterior debridement

N = 12

ND ND 8%

Failure 0%

Relapse 8%

Failure 0%

Relapse 0%

ND Follow-up: 38 months

Both approaches were reliable. Patients who underwent fixation of anterior spine attained improved postoperative outcome, including having less pain and significantly improved well-being

Lee 2014 [20]

(RCos)

Combined anterior and posterior surgery

N = 10

Transpedicular

curettage, posterior stabilization and drainage

42 91.9 days

65 days

0% Failure 0% 0%

6% Relapse 10% 0%

Failure 0%

Relapse 0%

Follow-up: 57 months

Transpedicular drainage and curettage is a useful method to treat patients with pyogenic spondylodiscitis with poor health condition

1 3

N = 26

Table 7 (continued)

Author/publication year/type of study

Surgical approach Positive microbial cultures (%)

Period of antibiotic treatment Further surgi-

cal intervention

Failure/relapse Mortal-

ity rate (%)

Conclusion of article

1 3

Lin 2014 [21] (RCoS)

Combined open anterior and posterior

N = 20

Combined percutaneous anterior and posterior

N = 25

80 25–80 days 0%

Failure 0% 0%

Relapse 0%

Failure 0%

Relapse 8%

Follow-up: 2 years

Anterior interbody fusion and debridement with a bone graft ensued marginally invasive percutaneous posterior instrumentation could be

a substitute treatment for pyogenic spondylodiscitis

Author’s personal copy

Rossbach 2014 [14] (RCS)

Surgical therapy with antibiotics surgical therapy

N = 120, extra patients with TLSO N = 46

55 ND 54.1% Failure ND Relapse ND

ND Follow-up: ND

Significant improvement in patients (complicated with neurological deficits caused by an epidural abscess) who underwent surgery

Schomacher [22] (RCoS)

TTN cage and antibiotic therapy

N = 21

PEEK cage and antibiotic therapy

N = 16

70.1 IV: 3–6 weeks Oral: 6–10 weeks

1. % ND
  0% ND
  ND Follow-up: 20.4 months
  ND The application of PEEK or TTN-cages did not affect the risk of infection or radiological results even with removal of the infected disc in these patients
  Vcelak 2014 [23] (RCoS)
  Two-stage posteroanterior surgery
  N = 23
  Dorsal transmuscular surgery
  European Spine JournalN = 8
  95 ND 8.5%
  11.2%
  Failure 4.0%
  Relapse 8.1% Failure
  0%
  Relapse 0%
  4.3
  0%
  Follow-up: 1 year
  The patients who underwent a dorsal transmuscular approach had a greater loss of sagittal stability with no clinical association
  
  European Spine Journal
  Author’s personal copy
  
  Conflict of interest None of the authors has any potential conflict of interest.
  
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Affiliations

Nageswary Appalanaidu1 · Roozbeh Shafafy1 · Christopher Gee1 · Kit Brogan1 · Shuaib Karmani1 · Giuseppe Morassi1 · Sherief Elsayed1

 Sherief Elsayed sherief.elsayed@bsuh.nhs.uk

1 Brighton and Sussex University Hospitals NHS Trust, Brighton, UK

Source: researchgate.net

Predicting the need for surgical intervention in patients with spondylodiscitis: the Brighton Spondylodiscitis Score (BSDS)

Predicting the need for surgical intervention in patients with spondylodiscitis: the Brighton Spondylodiscitis Score (BSDS)

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