Regional Spondylodiscitis Disparities: Impact on Pathogen Spectrum and Patients.

Background: Spondylodiscitis is an infectious disease affecting an intervertebral disc and the adjacent vertebral bodies and is often the complication of a distant focus of infection. This study aims to ascertain the regional and hospital-specific disparities in bacterial patterns and resistance profiles in spontaneous and iatrogenic spondylodiscitis and their implications for patient treatment. Methods: We enrolled patients from two German hospitals, specifically comparing a university hospital (UVH) with a peripheral non-university hospital (NUH). We documented patient demographics, laboratory results, and surgical interventions. Microbiological assessments, antibiotic regimens, treatment durations, and resistance profiles were recorded. Results: This study included 135 patients. Upon admission, 92.4% reported pain, with 16.2% also presenting neurological deficits. The primary microbial species identified in both the UVH and NUH cohorts were S. aureus (37.3% vs. 31.3%) and cog. neg. staphylococci (28.8% vs. 34.4%), respectively. Notably, a higher prevalence of resistant bacteria was noted in the UVH group (p < 0.001). Additionally, concomitant malignancies were significantly more prevalent in the UVH cohort. Conclusion: Significant regional variations exist in bacterial prevalence and resistance profiles. Consequently, treatment protocols need to consider these nuances and undergo regular critical evaluation. Moreover, patients with concurrent malignancies face an elevated risk of spondylodiscitis.

A Combined Cyto- and Histopathological Diagnostic Approach Reduces Time to Diagnosis and Time to Therapy in First Manifestation of Metastatic Spinal Disease: A Cohort Study.

Malignant spinal lesions (MSLs) are frequently the first manifestation of malignant disease. Spinal care, diagnostic evaluation, and the initiation of systemic therapy are crucial for outcomes in patients (pts) with advanced cancer. However, histopathology (HP) may be time consuming. The additional evaluation of spinal lesions using cytopathology (CP) has the potential to reduce the time to diagnosis (TTD) and time to therapy (TTT). CP and HP specimens from spinal lesions were evaluated in parallel in 61 pts (CP/HP group). Furthermore, 139 pts in whom only HP was performed were analyzed (HP group). We analyzed the TTD of CP and HP within the CP/HP group. Furthermore, we compared the TTD and TTT between the groups. The mean TTD in CP was 1.7 ± 1.7 days (d) and 8.4 ± 3.6 d in HP (p < 0.001). In 13 pts in the CP/HP group (24.1%), specific therapy was initiated based on the CP findings in combination with imaging and biomarker results before completion of HP. The mean TTT in the CP/HP group was 21.0 ± 15.8 d and was significantly shorter compared to the HP group (28.6 ± 23.3 d) (p = 0.034). Concurrent CP for MSLs significantly reduces the TTD and TTT. As a result, incorporating concurrent CP for analyzing spinal lesions suspected of malignancy might have the potential to enhance pts' quality of life and prognosis in advanced cancer. Therefore, we recommend implementing CP as a standard procedure for the evaluation of MSLs.

Surgical Site Cytology to Diagnose Spinal Lesions.

Patients with new-onset malignant spinal lesions often have an urgent need for local spine intervention and systemic therapy. For optimal management, it is crucial to diagnose the underlying disease as quickly and reliably as possible. The aim of our current study was to determine the feasibility, sensitivity, specificity, and diagnostic certainty of complementary cytological evaluation of spinal lesions suspected of malignancy. In 44 patients, we performed histopathological biopsies and in parallel cytologic preparations from the malignant site. Cytological smears were prepared and stained for May-Grunwald and Giemsa. Bone biopsies were histopathologically analyzed according to the existing standard-of-care practices. In 42 of 44 cases (95%), a cytological sample was successfully obtained. In 40 cases (95.2%, Cohen's kappa: 0.77), the cytological diagnosis agreed with the histological diagnosis regarding the identification of a malignant lesion. This resulted in a sensitivity of 97% and a specificity of 80% as well as a diagnostic safety of 95%. Cytological analysis in the context of spinal surgery proved sufficient to establish a diagnosis of malignancy or its exclusion, expanding the existing diagnostic spectrum. Furthermore, implementation of this process as a routine clinical diagnostic might shorten the time to diagnosis and improve the treatment of this vulnerable patient group.

Outcome after Posterior Vertebral Column Resection in Patients with Severe Osteoporotic Fractures-A Retrospective Analysis from Two Centers.

Background and Objectives: In osteoporotic fractures of the spine with resulting kyphosis and threatening compression of neural structures, therapeutic decisions are difficult. The posterior vertebral column resection (pVCR) has been described by different authors as a surgical treatment in a single-stage posterior procedure. The aim of this study is to evaluate midterm outcomes of patients treated by pVCR due to severe osteoporotic fractures. Materials and Methods: Retrospective data analysis of all the patients treated for osteoporotic fractures by pVCR from 2012-2020 at two centers was performed. Demographic data, visual analog scale (VAS), Frankel scale (FS), Karnofsky performance status (KPS), radiological result and spinal fusion rates were evaluated. Results: A total of 17 patients were included. The mean age was 70 ± 10.2 y. The mean VAS decreased significantly from 7.7 ± 2.8 preoperatively to 3.0 ± 1.6 at last follow-up (p < 0.001) and the segmental kyphosis decreased from 29.4 ± 14.1° to 7.9 ± 8.0° (p < 0.001). The neurologic function on the FS did not worsen in any and improved in four of the patients. The median KPS remained stable over the whole observation period (70% vs. 70%). Spinal fusion was observed in nine out of nine patients who received CT follow-up >120 days after index surgery. Conclusions: This study showed that pVCR is a safe surgical technique with few surgical complications and no neurological deterioration considering the cohort. The patients' segmental kyphosis and VAS improved significantly, while the KPS remained stable.

The Hamburg Spondylodiscitis Assessment Score (HSAS) for Immediate Evaluation of Mortality Risk on Hospital Admission.

(1) Background: Patients with spondylodiscitis often present with unspecific and heterogeneous symptoms that delay diagnosis and inevitable therapeutic steps leading to increased mortality rates of up to 27%. A rapid initial triage is essential to identify patients at risk for a complicative disease course. We therefore aimed to develop a risk assessment score using fast available parameters to predict in-hospital mortality of patients admitted with spondylodiscitis. (2) Methods: A retrospective data analysis of 307 patients with spondylodiscitis recruited from 2013 to 2020 was carried out. Patients were grouped according to all-cause mortality. Via logistic regression, individual patient and clinical characteristics predictive of mortality were identified. A weighted sum score to estimate a patient's risk of mortality was developed and validated in a randomly selected subgroup of spondylodiscitis patients. (3) Results: 14% of patients with spondylodiscitis died during their in-hospital stay at a tertiary center for spinal surgery. Univariate and logistic regression analyses of parameters recorded at hospital admission showed that age older than 72.5 years, rheumatoid arthritis, creatinine > 1.29 mg/dL and CRP > 140.5 mg/L increased the risk of mortality 3.9-fold, 9.4-fold, 4.3-fold and 4.1-fold, respectively. S. aureus detection increased the risk of mortality by 2.3-fold. (4) Conclusions: The novel Hamburg Spondylodiscitis Assessment Score (HSAS) shows a good fit identifying patients at low-, moderate-, high- and very high risk for in hospital mortality on admission (AUC: 0.795; p < 0.001). The implementation of the HSAS into clinical practice could ease identification of high-risk patients using readily available parameters alone, improving the patient's safety and outcome.

Destructive per continuitatem spondylodiscitis after endovascular abdominal or thoracic aneurysm repair (EVAR/TEVAR): rare and untreatable?

INTRODUCTION: Very few publications have previously described spondylodiscitis as a potential complication of endovascular aortic procedures (EVAR/TEVAR). We present to our knowledge the first case series of spondylodiscitis following EVAR/TEVAR based on our data base. Particular focus was laid on the complexity of disease treatment and grave outcome perspectives from a spine surgeon's point of view in this seriously affected patient group. MATERIALS AND METHODS: A retrospective analysis and chart review was performed for 11 out of 284 consecutive spondylodiscitis patients who underwent EVAR/TEVAR procedure and developed destructive per continuitatem spondylodiscitis. RESULTS: All 11 patients had single or more level destructive spondylodiscitis adjacent to the thoracic/lumbar stent graft. In mean, four surgeries were performed per patient to treat this rare complication. Six out of eleven patients (55%) died within 6 months of first identification of per continuitatem spondylodiscitis. In four patients due to persisting infection of the graft and recurrence of the abscess formation, a persisting fistula from anterior approach to the skin was applied. CONCLUSIONS: Destructive per continuitatem spondylodiscitis is a rare and severe complication post-EVAR/TEVAR. Clinical and imaging features of anterior paravertebral disease and anterior vertebral body involvement suggest direct continuous spread of the graft infection to the adjacent vertebral column. The mortality rate of these severe infections is extremely high and treatment with a permanent fistula may be one salvage procedure.

Surgical management of spinal metastases involving the cervicothoracic junction: results of a multicenter, European observational study.

OBJECTIVE: Surgical management of spinal metastases at the cervicothoracic junction (CTJ) is highly complex and relies on case-based decision-making. The aim of this multicentric study was to describe surgical procedures for metastases at the CTJ and provide guidance for clinical and surgical management. METHODS: Patients eligible for this study were those with metastases at the CTJ (C7-T2) who had been consecutively treated in 2005-2019 at 7 academic institutions across Europe. The Spine Instability Neoplastic Score, neurological function, clinical status, medical history, and surgical data for each patient were retrospectively assessed. Patients were divided into four surgical groups: 1) posterior decompression only, 2) posterior decompression and fusion, 3) anterior corpectomy and fusion, and 4) anterior corpectomy and 360° fusion. Endpoints were complications, surgical revision rate, and survival. RESULTS: Among the 238 patients eligible for inclusion this study, 37 were included in group 1 (15%), 127 in group 2 (53%), 18 in group 3 (8%), and 56 in group 4 (24%). Mechanical pain was the predominant symptom (79%, 189 patients). Surgical complications occurred in 16% (group 1), 20% (group 2), 11% (group 3), and 18% (group 4). Of these, hardware failure (HwF) occurred in 18% and led to surgical revision in 7 of 8 cases. The overall complication rate was 34%. In-hospital mortality was 5%. CONCLUSIONS: Posterior fusion and decompression was the most frequently used technique. Care should be taken to choose instrumentation techniques that offer the highest possible biomechanical load-bearing capacity to avoid HwF. Since the overall complication rate is high, the prevention of in-hospital complications seems crucial to reduce in-hospital mortality.

Posterior vertebral column resection as a safe procedure leading to solid bone fusion in metastatic epidural spinal cord compression.

OBJECTIVE: Cancer is one of the leading causes of death and greatly decreases a patient's quality of life. Vertebral metastases often lead to epidural spinal cord compression (ESCC) requiring surgical therapy. It has previously been shown that in patients with metastatic ESCC (MESCC), a surgical intervention leads to an improved outcome. Although the treatment paradigms in spinal metastases have changed and separation surgery followed by stereotactic radiosurgery is considered the best strategy, there are still cases in which 360° decompression with stabilization is indicated. In these patients, a proper bone fusion should be the treatment goal to guarantee good clinical results in extended survival times through progressions in oncological therapies. The aim of this study was to examine the safety and feasibility of posterior vertebral column resection (pVCR) in everyday clinical practice, achievement of bone fusion, and midterm outcome in patients with MESCC. METHODS: All patients treated with pVCR due to MESCC between 2013 and 2020 were enrolled in this observational single-center study. Demographics, outcome parameters, numeric rating scale (NRS) score, Frankel grade, and Karnofsky Performance Scale (KPS) score were evaluated. Radiological images routinely acquired during follow-up were reviewed and screened for the presence of bone fusion. RESULTS: Sixty-six patients were treated by eight surgeons. The mean follow-up period was 549 ± 739 days. At baseline, the average age was 64.4 ± 10.9 years. Reported NRS scores (preoperative 6.2 ± 1.7 vs postoperative 3.4 ± 1.6) and segmental kyphosis as measured on sagittal CT images (preoperative 13.5° ± 8.6° vs postoperative 3.8° ± 5.4°) decreased significantly (p < 0.001). In only 2 patients (3%), the Frankel grade worsened postoperatively, whereas in 12 patients (18.2%) an improvement was documented. The KPS score remained constant during the observation period (preoperative 73.2% ± 18.2% vs 78.3% ± 18% at last follow-up). Bone fusion was observed in 26 patients (86.7%) receiving CT more than 100 days after the index surgery. CONCLUSIONS: pVCR is a reliable surgical technique in daily clinical practice, which proves to be beneficial in terms of short- as well as midterm outcome, as judged by the KPS and NRS. The overall improvement in the Frankel grade shows patient safety. A bone fusion was observed regularly in oncological patients undergoing pVCR. The authors therefore conclude that pVCR is a safe, fast, and efficient strategy to achieve stability and pain relief by achievement of bone fusion in cancer patients.

Intraoperative blood loss in oncological spine surgery.

OBJECTIVE: Intraoperative blood loss in patients undergoing oncological spine surgery poses a major challenge for vulnerable patients. The goal of this study was to assess how the surgical procedure, tumor type, and tumor anatomy, as well as anesthesiological parameters, affect intraoperative blood loss in oncological spine surgery and to use this information to generate a short preoperative checklist for spine surgeons and anesthesiologists to identify patients at risk for increased intraoperative blood loss. METHODS: The authors performed a retrospective analysis of 430 oncological patients who underwent spine surgery between 2013 and 2018 at the university medical spine center. Enrolled patients had metastatic tumor of the spine requiring surgical decompression of neural structures and/or stabilization including tumor biopsy using an open, percutaneous, and/or combined dorsoventral approach. Patients requiring vertebro- and kyphoplasty or biopsy only were excluded. Statistical analyses performed included a multiple linear regression analysis. RESULTS: The mean intraoperative blood loss in the study patient cohort was 1176 ± 1209 ml. In total, 33.8% of patients received intraoperative red blood cell transfusions. The statistical analyses showed that tumor histology indicating myeloma, operative procedure length, epidural spinal cord compression (ESCC) score, tumor localization, BMI, and surgical strategy were significantly associated with increased intraoperative blood loss or risk of needing allogeneic blood transfusions. Anesthesiological parameters such as the American Society of Anesthesiologists (ASA) Physical Status classification score were not associated with blood loss. Multiple linear regression analysis demonstrated good predictive value (r = 0.437) for a five-item preoperative checklist to identify patients at risk for high intraoperative blood loss. CONCLUSIONS: The analyses performed in this study demonstrated key factors affecting intraoperative blood loss and showed that a simple preoperative checklist including these factors can be used to identify patients undergoing surgery for metastatic spine tumors who are at risk for increased intraoperative blood loss. ABBREVIATIONS: ABT = allogeneic blood transfusion; ASA = American Society of Anesthesiologists; ESCC = epidural spinal cord compression; KW = Kruskal-Wallis; MET = metabolic equivalent of task; RBC = red blood cell.

Carbon fiber-reinforced PEEK versus titanium implants: an in vitro comparison of susceptibility artifacts in CT and MR imaging.

Artifacts in computed tomography (CT) and magnetic resonance imaging (MRI) due to titanium implants in spine surgery are known to cause difficulties in follow-up imaging, radiation planning, and precise dose delivery in patients with spinal tumors. Carbon fiber-reinforced polyetheretherketon (CFRP) implants aim to reduce these artifacts. Our aim was to analyze susceptibility artifacts of these implants using a standardized in vitro model. Titanium and CFRP screw-rod phantoms were embedded in 3% agarose gel. Phantoms were scanned with Siemens Somatom AS Open and 3.0-T Siemens Skyra scanners. Regions of interest (ROIs) were plotted and analyzed for CT and MRI at clinically relevant localizations. CT voxel-based imaging analysis showed a significant difference of artifact intensity and central overlay between titanium and CFRP phantoms. For the virtual regions of the spinal canal, titanium implants (ti) presented - 30.7 HU vs. 33.4 HU mean for CFRP (p < 0.001), at the posterior margin of the vertebral body 68.9 HU (ti) vs. 59.8 HU (CFRP) (p < 0.001) and at the anterior part of the vertebral body 201.2 HU (ti) vs. 70.4 HU (CFRP) (p < 0.001), respectively. MRI data was only visually interpreted due to the low sample size and lack of an objective measuring system as Hounsfield units in CT. CT imaging of the phantom with typical implant configuration for thoracic stabilization could demonstrate a significant artifact reduction in CFRP implants compared with titanium implants for evaluation of index structures. Radiolucency with less artifacts provides a better interpretation of follow-up imaging, radiation planning, and more precise dose delivery.

Obesity in spontaneous spondylodiscitis: a relevant risk factor for severe disease courses.

Spondylodiscitis is a serious and potentially life-threatening disease. Obesity is a risk factor for many infections, and its prevalence is increasing worldwide. Thus, the aim of this study was to describe characteristics of obese patients with spondylodiscitis and identify risk factors for a severe disease course in obese patients. Between December 2012 and June 2018, clinical records were screened for patients admitted for spondylodiscitis. The final analysis included 191 adult patients (mean age 64.6 ± 14.8 years). Patient data concerning demographics, comorbidities, surgical treatment, laboratory testing, and microbiological workup were analysed using an electronic database. Patients were grouped according to body mass index (BMI) as BMI ≥ 30 kg/m2 or < 30 kg/m2. Seventy-seven patients were classified as normal weight (BMI 18.5-24.9 kg/m2), 65 as preobese (BMI 25-29.9 kg/m2), and 49 as obese (BMI ≥ 30 kg/m2). Obese patients were younger, had a higher revision surgery rate, and showed higher rates of abscesses, neurological failure, and postoperative complications. A different bacterial spectrum dominated by staphylococci species was revealed (p = 0.019). Obese patients with diabetes mellitus had a significantly higher risk for spondylodiscitis (p = 0.002). The mortality rate was similar in both cohorts, as was the spondylodiscitis localisation. Obesity, especially when combined with diabetes mellitus, is associated with a higher proportion of Staphylococcus aureus infections and is a risk factor for a severe course of spondylodiscitis, including higher revision rates and sepsis, especially in younger patients.

Impact of the localization on disease course and clinical management in spondylodiscitis.

OBJECTIVES: Spondylodiscitis is a severe infection of the spine that can take a diverse number of disease courses depending on its localization, resulting in specific therapeutic strategies. This study aims to identify localization specific characteristics and clinical parameters for spondylodiscitis. METHODS: A retrospective review was performed of 211 patients from 2013-2018 with proven spondylodiscitis. In total, 33 were cervical, 48 thoracic and 112 lumbar. In 18 patients disseminated infestations of several localizations were found. The patient records were evaluated for clinical and outcome parameters and demographic characteristics. RESULTS: Patient age, Body Mass Index, inpatient and intensive care stay, and inpatient complications did not differ significantly between different infection localizations. C-reactive protein (CrP) levels showed a significantly reduced value in the thoracic area compared to other localizations. For comorbidities, there was a significantly higher prevalence of endocarditis in disseminated and lumbar infestations compared to thoracic and cervical cases. Epidural abscesses showed a highly increased incidence in cervical cases. With a 30-day mortality rate of 12.1% for cervical, 12.5% thoracic, 13.4% lumbar, and 22.2% in disseminated disease, no significant difference was observed. CONCLUSIONS: The present study determined that, although the 30-day mortality rate does not differ according to the localization of the infection, specific clinical parameters, such as CrP values or comorbidities, showed localization-dependent differences.

Cervical vertebroplasty for osteolytic metastases as a minimally invasive therapeutic option in oncological surgery: outcome in 14 cases.

OBJECTIVE The treatment of cervical spinal metastases represents a controversial issue regarding the type, extent, and invasiveness of interventions. In the lumbar and thoracic spine, kypho- and vertebroplasties have been established as minimally invasive procedures for patients with metastases to the vertebral bodies and without neurological deficit. These procedures show good results with respect to pain reduction and low complication rates. However, limited data are available for kypho- and vertebroplasties for cervical spinal metastases. In an effort to add to existing data, the authors here present a case series of 14 patients who were treated for osteolytic metastases of the cervical spine using vertebroplasty alone or in addition to another surgical procedure involving the cervical spine in a palliative setting to reduce pain and restore stability. METHODS Fourteen patients consisting of 8 males and 6 females, with a mean age of 64.7 years (range 44-85 years), were treated with vertebroplasty at the authors' clinic between January 2015 and November 2016. In total, 25 vertebrae were treated with vertebroplasty: 10 C-2, 5 C-3, 2 C-4, 2 C-5, 3 C-6, and 3 C-7. Two patients had an additional posterior stabilization and 5 patients an additional anterior stabilization. In 13 cases, the surgical approach was a modified Smith-Robinson approach; in 1 case, the cement was injected into the corpus axis from posteriorly. Patients with osteolytic defects of the posterior wall of the vertebral body did not undergo surgery, nor did patients with neurological deficits. Preoperatively, on the 2nd day after surgery, and at the follow-up, neck pain was rated using the visual analog scale (VAS). RESULTS Twelve patients were examined at follow-up (mean 9 months). Neck pain was rated as a mean of 6.0 (range 3-8) preoperatively, 2.9 on Day 2 after surgery (range 0-5), and 0.5 at the follow-up (range 0-4), according to the VAS. The mean Neck Disability Index at follow-up was 3.6% (range 0%-18%). CONCLUSIONS Anterior vertebroplasty of the cervical spine via an anterolateral approach represents a safe and minimally invasive procedure with a low complication rate and appears suitable for reducing pain and restoring stability in cases of cervical spinal metastases. Vertebroplasties can be combined with other anterior and posterior operations of the cervical spine and, in the axis vertebra, can be performed transpedicularly from posteriorly. Thus, in cases in which the posterior wall of the vertebral body is intact, vertebroplasty represents a less invasive alternative to vertebral replacement in oncological surgery. Prospective randomized trials with a longer follow-up period and a larger patient cohort are needed to confirm the encouraging results of this case series.

Lumbar Neuroforaminal Decompression with a Flexible Microblade Shaver System: Results of a Cadaveric Study.

BACKGROUND: The lumbar neural foraminal stenosis still is a challenging condition in minimally invasive spine surgery. Because of the anatomic situation a complete decompression of the nerve root often leads to a subtotal facetectomy associated with potential instability and the need for additional instrumentation of the decompressed segment. The iO-Flex system was introduced to address this problem by using a minimally invasive wire-guided microblade shaver to increase the neuroforaminal space by reducing the stenosis from intraforaminal while sparing bigger parts of the facet joint. In this study, we evaluated the feasibility and the surgical and radiological success in relation to the experience of the surgeon. METHODS: We performed decompression of the neuroforamen in 10 lumbar levels of 2 fresh-frozen human cadavers. Before and after decompression, we obtained high-resolution computed tomography data to evaluate the diameter of the neural foramen. RESULTS: The mean foraminal width (7.88-10.94 mm, P < 0.0001) and area (123.27-149.18 mm2, P < 0.003) increased significantly after the decompression, whereas the facet joints area (131.9-107.51 mm2, P < 0.005) and width (16.4-13.75 mm, P < 0.001) indeed decreased significantly but with an overall reduction of facet joint width by 16% and facet joint area by 18%. No complications such as nerve root damages or dural tears were observed. CONCLUSIONS: The flexible micro blade shaver system is feasible with a steep learning curve and achieves sufficient decompression of the neuroforamen in this cadaveric study.