Minimally invasive surgery for the treatment of thoraco lumbar pyogenic spondylodiscitis: indications and outcomes.

OBJECTIVE: Pyogenic spondylodiscitis (PS) is a non-specific infection affecting intervertebral disks and adjacent vertebral bodies. Once considered a rare condition in developed countries, the incidence of PS has been increasing alarmingly and still represents a challenge for clinicians and orthopedic surgeons. New minimally invasive techniques have been proposed but the proper indications for these different approaches remain controversial. The aim of this study was to describe the available minimally invasive surgical techniques and to evaluate their proper indications through a review of recent literature. MATERIALS AND METHODS: Over 30 articles of recent scientific literature have been reviewed and analyzed. Studies were searched through the PubMed database using the key words: spondylodiscitis, minimally invasive, and surgical treatment. The most interesting and valid techniques and results have been reported. Despite the exclusion of case reports, all the available studies have been conducted on small groups of patients. Indications for each technique have been reported according to a clinical-radiological classification of PS. RESULTS: Six of the most widely used minimally invasive surgical techniques have been described.  High success rates have been reported in terms of preventing the progression of spondylodiscitis into more destructive forms, reduction of time and operative hospitalization, faster pain relief, early mobilization, and achievement of microbiological diagnosis. CONCLUSIONS: The role of minimally invasive surgery in the treatment of PS is rapidly expanding. Reducing surgery-related morbidity in these frail patients is possible and often necessary. However, while more and more new techniques are being proposed, still few clinical data are available. Clinical comparison studies with open traditional surgery should be encouraged, and more attention should be paid to long-term outcomes. For the present, the indications for minimally invasive procedures should, therefore, be evaluated on a case by case basis and on clinical and radiological findings.

Multidisciplinary management of pyogenic spondylodiscitis: epidemiological and clinical features, prognostic factors and long-term outcomes in 207 patients.

PURPOSE: Pyogenic spondylodiscitis (PS) is a potentially life-threatening infection burdened by high morbidity rates. Despite the rising incidence, the proper management of PS is still controversial. Aim of this study was to describe the clinical features of PS and to evaluate the prognostic factors and the long-term outcomes of a large population of patients. METHODS: 207 cases of PS treated from 2008 to 2016 with a 2-year follow-up were enrolled. Clinical data from each patient were recorded. The primary outcome was the rate of healing without residual disability. Secondary outcomes included length of stay, healing from infection, death, relapse, and residual disability. Binomial logistic regression and multivariate analysis were used to evaluate prognostic factors. RESULTS: Median diagnostic delay was 30 days and the rate of onset neurological impairment was 23.6%. Microbiological diagnosis was established in 155 patients (74.3%) and the median duration of total antibiotic therapy was 148 days. Orthopedic treatment was conservative for 124 patients and surgical in 47 cases. Complete healing without disability was achieved in 142 patients (77.6%). Statistically confirmed negative prognostic factors were: negative microbiological culture, neurologic impairment at diagnosis and underlying endocarditis (p ≤ 0.05). Healing from infection rate was 90.9%, while residual disabilities occurred in 23.5%. Observed mortality rate was 7.8%. CONCLUSION: The microbiological diagnosis is the main predictive factor for successful treatment. Early diagnosis and multidisciplinary management are also needed to identify underlying aggressive conditions and to avoid neurological complications associated with poorer long-term outcomes. Despite high healing rates, PS may lead to major disabilities still representing a difficult challenge. These slides can be retrieved under Electronic Supplementary material.

New classification for the treatment of pyogenic spondylodiscitis: validation study on a population of 250 patients with a follow-up of 2 years.

PURPOSE: Pyogenic spondylodiscitis (PS) is still burdened by a high rate of orthopedic and neurological complications. Despite the rising incidence, the choice of a proper orthopedic treatment is often delayed by the lack of clinical data. The aim of this study was to propose a clinical-radiological classification of pyogenic spondylodiscitis to define a standard treatment algorithm. METHODS: Based on data from 250 patients treated from 2008 to 2015, a clinical-radiological classification of pyogenic spondylodiscitis was developed. According to primary classification criteria (bone destruction or segmental instability, epidural abscesses and neurological impairment), three main classes were identified. Subclasses were defined according to secondary criteria. PS without segmental instability or neurological impairment was treated conservatively. When significant bone loss or neurological impairment occurred, surgical stabilization and/or decompression were performed. All patients underwent clinical and radiological 2-year follow-up. RESULTS: Type A PS occurred in 84 patients, while 46 cases were classified as type B and 120 as type C. Average time of hospitalization was 51.94 days and overall healing rate was 92.80%. 140 patients (56.00%) were treated conservatively with average time of immobilization of 218.17 ± 9.89 days. Both VAS and SF-12 scores improved across time points in all classes. Residual chronic back pain occurred in 27 patients (10.80%). Overall observed mortality was 4.80%. CONCLUSIONS: Standardized treatment of PS is highly recommended to ensure patients a good quality of life. The proposed scheme includes all available orthopedic treatments and helps spine surgeons to significantly reduce complications and costs and to avoid overtreatment.

Pregnancy-associated osteoporosis (PAO) with multiple vertebral fragility fractures: diagnosis and treatment in a young primigravid woman.

PAO is an uncommon condition affecting pregnant women during last trimester or early post-delivery period; it is often asymptomatic or presents with pain related to some acute fragility fractures. The diagnosis is often delayed or missed, the etiology remains unknown and no guidelines about treatment have been published. We present one case of PAO in a 33-year-old primigravid woman presenting acute worsening back pain. Our patient was treated with a TLSO brace, oral 25 (OH)-vitamin D supplementation and Teriparatide for 6 months. A short review of the literature has been included and useful advice about how to suspect and diagnose this uncommon disease were given in order to recognize and treat such a debilitating and severe condition for young mothers as best as possible, based on the available scientific evidences.

Kyphoplasty vs conservative treatment: a case-control study in 110 post-menopausal women population. Is kyphoplasty better than conservative treatment?

OBJECTIVE: Osteoporosis is a highly prevalent disease worldwide. Consequences of vertebral osteoporotic fractures include pain and progressive vertebral collapse resulting in spinal kyphosis, decreased quality of life, disability and mortality. Minimally invasive procedures represent an advance to the treatment of osteoporotic VCFs. Despite encouraging results reported by many authors, surgical intervention in an osteoporotic spine is fraught with difficulties. Advanced patients age and comorbidities are of great concern. PATIENTS AND METHODS: We designed a retrospective case-control study on 110 post-menopausal women consecutively visited at our institution. Study population was split in a surgical and a conservative cohort, according to the provided treatment. RESULTS: Kyphoplasty treated patients had lower back pain VAS scores at 1 month as compared with conservatively treated patients (p < 0.05). EQ5D validated questionnaire also showed a better quality of life at 1 month for surgically treated patients (p < 0.05). SF-12 scores showed greater improvements at 1 month and 3 months with statistically significant difference between the two groups just at 3 months (p < 0.05). At 12 months, scores from all scales were not statistically different between the two cohorts, although surgically treated patients showed better trends than conservatively treated patients in pain and quality of life. Kyphoplasty was able to restore more than 54.55% of the original segmental kyphosis, whereas patients in conservative cohort lost 6.67% of the original segmental kyphosis on average. CONCLUSIONS: Kyphoplasty is a modern minimal invasive surgery, allowing faster recovery than bracing treatment. It can avoid the deformity in kyphosis due to VCF. In fact, the risk to develop a new vertebral fracture after the first one is very high.