Biomechanical comparative study of midline cortical vs. traditional pedicle screw trajectory in osteoporotic bone.

INTRODUCTION: In lumbar spinal stabilization pedicle screws are used as standard. However, especially in osteoporosis, screw anchorage is a problem. Cortical bone trajectory (CBT) is an alternative technique designed to increase stability without the use of cement. In this regard, comparative studies showed biomechanical superiority of the MC (midline cortical bone trajectory) technique with longer cortical progression over the CBT technique. The aim of this biomechanical study was to comparatively investigate the MC technique against the not cemented pedicle screws (TT) in terms of their pullout forces and anchorage properties during sagittal cyclic loading according to the ASTM F1717 test. METHODS: Five cadavers (L1 to L5), whose mean age was 83.3 ± 9.9 years and mean T Score of -3.92 ± 0.38, were dissected and the vertebral bodies embedded in polyurethane casting resin. Then, one screw was randomly inserted into each vertebra using a template according to the MC technique and a second one was inserted by freehand technique with traditional trajectory (TT). The screws were quasi-static extracted from vertebrae L1 and L3, while for L2, L4 and L5 they were first tested dynamically according to ASTM standard F1717 (10,000 cycles at 1 Hz between 10 and 110 N) and then quasi-static extracted. In order to determine possible screw loosening, there movements were recorded during the dynamic tests using an optical measurement system. RESULTS: The pull-out tests show a higher pull-out strength for the MC technique of 555.4 ± 237.0 N compared to the TT technique 448.8 ± 303.2 N. During the dynamic tests (L2, L4, L5), 8 out of the 15 TT screws became loose before completing 10,000 cycles. In contrast, all 15 MC screws did not exceed the termination criterion and were thus able to complete the full test procedure. For the runners, the optical measurement showed greater relative movement of the TT variant compared to the MC variant. The pull-out tests also revealed that the MC variant had a higher pull-out strength, measuring at766.7 ± 385.4 N, while the TT variant measured 637.4 ± 435.6 N. CONCLUSION: The highest pullout forces were achieved by the MC technique. The main difference between the techniques was observed in the dynamic measurements, where the MC technique exhibited superior primary stability compared to the conventional technique in terms of primary stability. Overall, the MC technique in combination with template-guided insertion represents the best alternative for anchoring screws in osteoporotic bone without cement.

Spondylodiscitis in Geriatric Patients: What Are the Issues?

STUDY DESIGN: Review article. OBJECTIVES: A review of literature on the treatment of pyogenic spondylodiscitis in geriatric patients was performed with the aim to give an overview about these special patients and a recommendation on necessary diagnostics as well as conservative and operative treatment options. METHODS: A systematic computerized literature search was done by the spondylodiscitis working group of the German Society for Orthopedics and Trauma Surgery. RESULTS: Spondylodiscitis has an increasing incidence by age with a peak at 75 years or older. The 1-year mortality without an appropriate treatment is with 15 to 20% extremely high. Pathogen detection is the essential diagnostic step and the basis for a sufficient antibiotic treatment. Geriatric patients have initially less elevated inflammatory parameters. Compared to younger patients. They have a longer length of hospital stay and take longer for CRP normalization. Even the outcome between conservative and operative treatment is comparable after one year. Patients with spinal instability, immobilizing pain, epidural abscess, and newly emerged neurological deficits should be considered for operative treatment. CONCLUSIONS: The treatment of geriatric patients with pyogenic spondylodiscitis must take into account that these patients usually have multiple comorbidities. The main goals are resistance-based antibiotics and the shortest possible time of immobilization of the patient.

Imaging in the Diagnosis of Nonspecific Pyogenic Spondylodiskitis.

The prevalence of nonspecific pyogenic spondylodiskitis, associated with both a high morbidity and a high mortality, has increased in the last few decades. The diagnosis is often delayed because of the nonspecific clinical manifestation at the early stage. The reliability of radiographs is limited, particularly in early stage after the onset of infection. Computed tomography (CT) can reliably assess the bony condition with the possibility of spatial visualization. Contrast enhancement supports the detection of affected soft tissue. Magnetic resonance imaging (MRI) continues to be the gold standard in the diagnosis of spondylodiskitis. Sophisticated investigation protocols supported by gadolinium enhancement secure the diagnosis. MRI has a high resolution without radiation exposure. Different nuclear investigation techniques extend the diagnostic options. Reports of 18F-fluorodeoxyglucose-positron emission tomography (18-FDG-PET) are particularly promising to confirm the diagnosis. The drawback of the reduced image quality with respect to detailed anatomical information can be overcome by a combined simultaneous acquisition of CT or MRI. With respect to one of the greatest challenges, the differentiation between degenerative changes (Modic type 1) and infection at an early stage using differentiated MRI protocols and FDG-PET is promising. This overview presents a concise state-of-the-art look at radiologic investigations in case of suspected nonspecific pyogenic spondylodiskitis with the focus on a pragmatic approach.

A Biomechanical Model for Testing Cage Subsidence in Spine Specimens with Osteopenia or Osteoporosis Under Permanent Maximum Load.

BACKGROUND: Intervertebral fusions in cases of reduced bone density are a tough challenge. From a biomechanical point of view, most current studies have focused on the range of motion or have shown test setups for single-component tests. Definitive setups for biomechanical testing of the primary stability of a 360° fusion using a screw-rod system and cage on osteoporotic spine are missing. The aim of this study was to develop a test stand to provide information about the bone-implant interface under reproducible conditions. METHODS: After pretesting with artificial bone, functional spine units were tested with 360° fusion in the transforaminal lumbar interbody fusion technique. The movement sequences were conducted in flexion/extension, right and left lateral bending, and right and left axial rotation on a human model with osteopenia or osteoporosis under permanent maximum load with 7.5 N-m. RESULTS: During the testing of human cadavers, 4 vertebrae were fully tested and were inconspicuous even after radiological and macroscopic examination. One vertebra showed a subsidence of 2 mm, and 1 vertebra had a cage collapsed into the vertebra. CONCLUSIONS: This setup is suitable for biomechanical testing of cyclical continuous loads on the spine with reduced bone quality or osteoporosis. The embedding method is stable and ensures a purely single-level setup with different trajectories, especially when using the cortical bone trajectory. Optical monitoring provides a very accurate indication of cage movement, which correlates with the macroscopic and radiological results.

Total spine magnetic resonance imaging for detection of multifocal infection in pyogenic spondylodiscitis: a retrospective observational study.

BACKGROUND: Due to the unspecific symptoms of spondylodiscitis (SpD), an early radiological examination is necessary. However, controversially discussed is the need for magnetic resonance imaging of the entire spine to exclude multisegmental infections and to determine the required surgical interventions. The aims of this study were to assess the incidence of multilevel non-contiguous pyogenic SpD and compare comorbidities, pain symptoms, and subsequent surgical strategies between unifocal (uSpD) and multifocal (mSpD) SpD. METHODS: We retrospectively evaluated the data of patients with confirmed, surgically treated, pyogenic SpD who had received a total spine MRI in a single spine center between 2016 and 2018. MRI findings were classified according to Pola-classification and demographics, duration of clinical symptoms (pain and neurology) and Charlson Comorbidity-Index (CCI) results were compared between uSpD und mSpD groups. Surgical therapy was evaluated in patients with mSpD. RESULTS: uSpD was detected by MRI in 69 of 79 patients (87%). Of these, mSpD was detected in 10 patients (13%) with 21 infected segments (cervical and/ or thoracic and/ or lumbar region). Age and CCI were similar between uSpD and mSpD and 24 of all SpD regions were clinically unapparent. All patients with uSpD were treated operatively. In seven patients with mSpD, all infected levels of the spine were treated surgically in a one-stage procedure; one patient had a two-stage procedure and one patient had surgery at the lumbar spine, and an additional infected segment of the upper thoracic spine was treated conservatively. One patient died before a planned two-stage procedure was performed. CONCLUSIONS: Due to mSpD being found in approximately 13% of SpD cases, and considering the risk of overlooking an mSpD case, MRI imaging of the total spine is recommended. The detection of multiple infection levels can have an impact on the therapeutic strategy chosen.

Pyogenic Spondylodiscitis of the Thoracic Spine: Outcome of 1-Stage Posterior Versus 2-Stage Posterior and Anterior Spinal Reconstruction in Adults.

OBJECTIVE: The aim of this study was to compare the clinical, radiologic, and functional outcomes of a 1-stage posterior treatment versus a 2-stage posterior-anterior treatment in patients with pyogenic thoracic spondylodiscitis. METHODS: A 1-stage posterior debridement, stabilization, and fusion with titanium-coated polyetheretherketone (PEEK) or mesh cage through a dorsolateral approach was performed in group A. A 2-stage procedure with initial posterior stabilization and debridement and second-stage fusion with a PEEK cage or mesh cage was performed with an anterior approach in group B. Clinical outcomes included Oswestry Low Back Pain Disability Questionnaire and visual analog scale score. Radiologic outcomes included fusion rate and kyphotic angle correction. Secondary variables included pathogens, complications, blood loss, and operative time. RESULTS: One-level spondylodiscitis was treated surgically in the thoracic spine of 47 patients: 25 patients in group A and 22 patients in group B. The most frequent segment was T12-L1 (27%). There was a significantly longer operative time and greater blood loss (P > 0.001) in group B. At last follow-up, sagittal profile reconstruction was significantly better (P > 0.05) in group B. Both groups showed similar radiologic results with fusion in 92% of cases. Improved clinical outcomes, pain, and quality of life were achieved in both groups with no significant differences between the 2 groups. CONCLUSIONS: Better reconstruction of the sagittal profile was achieved in the posterior-anterior-treated group, but this did not affect the clinical outcome. No significant differences were found in the clinical and functional outcomes between the 2 groups. Posterior-anterior combined treatment should be considered in cases of large anterior defects if a posterior reconstruction is inadequate.

Balloon kyphoplasty and additional anterior odontoid screw fixation for treatment of unstable osteolytic lesions of the vertebral body C2: a case series.

BACKGROUND: Unstable osteolytic lesions of the occipitocervical junction are rare and may occur in hematological malignancy or vertebral hemangioma, among others. Different case reports have been published about vertebroplasty for treatment of spinal metastases of the upper cervical spine. Only few cases concern balloon kyphoplasty of C2. We present a consecutive case series including four patients with an osteolytic lesion of the dens axis and describe a technical note for balloon kyphoplasty of C2 and an additional anterior odontoid screw fixation. METHODS: Four consecutive patients with an osteolytic lesion of the vertebral body of C2 were treated by anterior balloon kyphoplasty and additional anterior odontoid screw fixation of the dens axis. The radiological imaging showed a lytic process of the vertebral body C2 with no vertebral collapse but involvement of more than 50% of the vertebral body in all patients. RESULTS: Two cases of potentially unstable osteolytic lesions of C2 by myeloma, one case with metastatic osteolytic lesion of C2 by adenocarcinoma of the colon and one patient with vertebral hemangioma located in C2 were presented to our clinic. In all cases, surgical treatment with an anterior balloon kyphoplasty of C2 and an additional anterior, bicortical odontoid screw placement was performed. Control x-rays showed sufficient osteosynthesis and cement placement in the vertebral body C2. DISCUSSION: Anterior balloon kyphoplasty and anterior odontoid screw placement is a safe treatment option for large osteolytic lesions of C2. The additional odontoid screw placement has the advantage of providing more stabilization and may prevent late complications, like odontoid fractures. For patients with potentially unstable or large osteolytic lesions of the dens without spinal cord compression or neurological symptoms we recommend the placement of an anterior odontoid screw when performing a balloon kyphoplasty. LEVEL OF EVIDENCE: - IV: retrospective or historical series.

Analysis of a Unilateral Bridging Cage for Lumbar Interbody Fusion: 2-Year Clinical Results and Fusion Rate with a Focus on Subsidence.

PURPOSE: The aim of this study was to evaluate the biomechanical stability and the clinical and radiographic outcomes in patients undergoing transforaminal lumbar interbody fusion (TLIF) using an oblique bridging cage with a particular focus on subsidence. METHODS: Finite element models were developed to compare the biomechanics of the oblique cage with conventional posterior lumbar interbody fusion and banana-shaped cages with TLIF. Additionally, a retrospective review of a prospective collected database was performed to investigate the clinical and radiologic results with a focus on the subsidence rate using an oblique polyetheretherketone (PEEK) cage with a bicortical load-bearing design. We included 87 patients with degenerative pathologic conditions of the lumbar spine who underwent TLIF. The clinical outcome was assessed using the Oswestry Low Back Pain Disability Questionnaire and the visual analogue scale. Fusion and subsidence rates were assessed radiographically. RESULTS: The finite element models showed no differences in stability on compression or extension/flexion. The oblique cage differed in terms of the location of the maximal stresses. A total of 105 levels were fused. The level at which fusion was most frequently performed was L4-L5 (59%). The fusion rate was 93.2% after 24 months. Subsidence was found at 4 levels after the last follow-up visit (3.9%). Overall clinical outcome improvement was achieved after 24 months. CONCLUSION: Regarding fusion, the use of an oblique PEEK cage with a cortical load-bearing design provided highly satisfactory clinical and radiologic results after 2 years. A review of the literature suggests a lower rate of cage subsidence after lumbar interbody fusion using bridging cages rather than single cages.

Single-stage debridement and spinal fusion using PEEK cages through a posterior approach for eradication of lumbar pyogenic spondylodiscitis: a safe treatment strategy for a detrimental condition.

BACKGROUND: Pyogenic infections of the lumbar spine are a rare but critical pathology, yet with considerably high mortality rates. In cases indicating surgical therapy, the implantation of titanium cages or autologous bone grafts represent today's gold standard. Although non-metallic implants such as poly-ether-ether-ketone (PEEK) have proven to be advantageous in diverse degenerative conditions, their saftey and practicability in lumbar spine infection remains questionable. Moreover, the efficacy of a single-step radical debridement of the infected disc space with subsequent fusion from a strictly posterior approach continues to be an issue of debate. We therefore sought to evaluate the feasibility, clinical and radiological outcome of a single-step TLIF procedure using oblique PEEK cages in the surgical management of patients with lumbar pyogenic spondylodiscitis. METHODS: From January 2009 through December 2013, all patients meeting the indication for surgical treatment of lumbar pyogenic spondylodiscitis were included. Patients demonstrating intact cortical bone on preoperative CT received a single-step radical debridement of the infected intervertebral disc space, posterior screw-and-rod instrumentation and implantation of an oblique PEEK cage using the TLIF technique. Oral antibiotics were continued for 12 weeks postoperatively and clinical and radiological results recorded throughout a minimum 1-year clinical follow-up. RESULTS: A total of 104 patients were admitted to receive surgical therapy for lumbar pyogenic spondylodiscitis. Within this patient population, 18 patients met the diagnostic criteria to receive the implantation of an oblique PEEK cage. Pathogens were detected in 13 cases with Staph. aureus being the predominant causative organism. All patients were discharged to recover in their domestic environment. Throughout the first year of clinical and radiological follow-up and beyond, none of the 18 patients demonstrated any signs of residual neurologic deficits or recurrent infection. Furthermore, two-plane conventional X-rays showed no significant implant subsidence or failure at any of the given time-points in up to 5 years postoperatively. CONCLUSIONS: In patients meeting the criteria for surgical treatment of lumbar pyogenic spondylodiscitis, the implantation of PEEK cages using a single-step TLIF approach is a safe and feasible procedure. Based on our experience, the concern of a recurrent infection when implanting non-metallic cages may be refuted in carefully selected patients.

Cervical spondylodiscitis with epidural abscess after knife stab wounds to the neck: A case report.

INTRODUCTION: Cervical spondylodiscitis is usually caused by pyogenic infections, associated with retropharyngeal abscesses, or due to the swallowing of foreign bodies. No cases of cervical spondylodiscitis caused by a penetrating neck injury have been published in the literature. We describe a case of cervical spondylodiscitis after multiple knife stab wounds to the lateral soft tissue of the neck. MATERIALS AND METHODS: Case report and review of the literature. RESULTS: A 54-year-old patient was brought to our clinic with destructive spondylodiscitis C3/4 with paravertebral and epidural abscesses. He had been involved in a fight and had suffered multiple stab wounds to his neck with a knife 1 month prior. The initial CT scan had revealed one deeper wound canal behind the sternocleidomastoid muscle on the left side without any injury to the vessels. The wound was cleaned and an antibiotic therapy with cefuroxime was given for 1 week. After an uneventful and complete healing of the wound the patient developed severe neck pain. Inflammatory laboratory parameters were elevated, and a MRI of the neck revealed a distinct spondylodiscitis C3/4 with paravertebral and epidural abscess formations. Surgery was performed and included debridement, abscess drainage, decompression of the spinal canal, fusion of the C3/4 segment using an autologous iliac crest bone graft and a plate osteosynthesis. A course of calculated antibiotic therapy was administered for 8 weeks. Normal laboratory parameters and no radiological signs of an ongoing inflammatory process were observed during follow-up examinations. The C3/4 segment was consolidated. CONCLUSION: Stab wound injuries to the neck not only bear the risk of injuries to the nerves, vessels and organs of the neck but also increase the risk of developing secondary spondylodiscitis. Specifically, cervical spondylodiscitis can result in distinct neurological symptoms, and surgical intervention should be performed in a timely manner.

Results after the surgical treatment of anterior cervical hyperostosis causing dysphagia.

PURPOSE: The objective of this study was to investigate the outcome of a case series of patients with dysphagia resulting from diffuse idiopathic skeletal hyperostosis (DISH) of the cervical spine who were treated surgically with resection and fusion. METHODS: A retrospective study was performed on all patients who presented (2005-2013) with complaints of dysphagia or respiratory compromise and who underwent anterior cervical osteophyte resection with fusion (polyether ether ketone cage and/or plate system) using an anterior approach. All patients were diagnosed with DISH and underwent preoperative esophageal and laryngoscopic examinations and a fluoroscopic swallowing study. Initial non-operative strategies were performed, including diet, change in head position during swallowing, non-steroidal anti-inflammatory drugs and pantoprazole. RESULTS: A total of six patients with DISH were included. The mean age was 67 ± 5 years. All patients were male and had symptoms of dysphagia and neck pain, one had simultaneous airway complaints, and another had regurgitation with a sleep disorder. All patients had significant improvements in dysphagia, respiratory complaints and regurgitation 6 weeks after surgery. The postoperative radiographs showed complete removal of the compressive structures. There were no postoperative complications. At the final follow-up (23 ± 8 months), the radiographic examinations showed no pathological regrowth, and the patients reported no recurrence of dysphagia. CONCLUSION: Diffuse idiopathic skeletal hyperostosis may lead to osteophyte-associated pathologies of the aerodigestive tract. Preoperative investigations with esophageal and laryngoscopic examinations combined with fluoroscopic swallowing tests are essential. Surgical decompression through osteophytectomy and fusion is an effective management strategy in selected patients and should be considered when non-operative strategies have failed.

Impact of a multidisciplinary pain program for the management of chronic low back pain in patients undergoing spine surgery and primary total hip replacement: a retrospective cohort study.

BACKGROUND: Low back pain is a very common disorder. In this field chronic low back pain represents a special challenge. The management of chronic low back pain consists of a range of different intervention strategies. Usually operative intervention should be avoided if possible. However, there are constellations were surgical therapy in patients with chronic low back pain seems to be meaningful. The aim of this study was to investigate the clinical outcomes after spine surgery and hip replacement in patients with chronic low back pain after undergoing a structured rehabilitation program including cognitive - behavioral therapy. METHODS: From January 1, 2007 to January 1, 2010 patients were indicated for total hip replacement (THA) or spine surgery after receiving inpatient multidisciplinary pain programs including cognitive - behavioral therapy at our orthopedic institute with a specialized unit for the rehabilitation of chronic pain patients. Indications for surgery were based on the synopsis of clinical and imaging findings and on positive effects after local injections during the multidisciplinary pain program. The tools for assessment included follow-up at 6 and 12 months and analyses of pain, chronicity, physical functioning and depression. RESULTS: Of the 256 patients admitted for multidisciplinary pain program, fifteen were indicated to benefit from a surgical intervention during multidisciplinary pain program. Ten patients received spine surgery. THA was indicated in five patients. In all cases, the peri- and postoperative clinical courses were uneventful. Only two of the patients subjected to spine surgery and three patients who had THA were improved after 12 months. One patient reported a worsened condition. All patients presented with good functional outcomes and normal radiological findings. CONCLUSIONS: The indication for surgical intervention in patients with chronic low back pain and degenerative diseases must be critically assessed. THA in this cohort should focus on functional aspects, such as the improvement of range of motion, rather than the reduction of pain. Spine surgery in chronic low back pain patients after multidisciplinary pain program including cognitive - behavioral therapy cannot be recommended due to its questionable success.

Non-union of osteoporotic vertebral fractures - identification and treatment of an underestimated pathology in elderly patients with persistent back pain.

OBJECTIVE: Non-union of osteoporotic vertebra fractures are a seldom entity. However, when back pain persists in the course of conservatively treated osteoporotic vertebra fractures, a non-union should be considered. We thus sought to validate our diagnostic algorithm in patients with known osteoporotic vertebra fractures presenting persistent back pain and advert to the diagnosis and treatment of vertebral non-unions. PATIENTS AND METHODS: Patients admitted with preexisting osteoporotic vertebra fractures and therapy-resistant back pain were retrospectively analysed. All admitted patients were subject to standard plain radiographs in erect position and conventional CT or MR imaging of the spine, respectively. In addition, patients with suspected non-union were subject to lateral fulcrum radiographs in supine position. RESULTS: From a total of 172 admitted patients, four patients presented with non-union of a fractured osteoporotic vertebra (2%). The subsequent surgical therapy included cement-augmented rod-and-screw stabilization, with or without additional correction of deformity, and kyphoplasty (N = 3) or kyphoplasty alone (N = 1). All surgical interventions were successful in pain reduction and allowed immediate and improved postoperative mobilisation. CONCLUSIONS: Non-union of osteoporotic vertebra fractures must be considered when symptoms outlast conservative treatment. In these cases, plain lateral fulcrum radiographs are a simple and effective adjunct to the conventional diagnostic methods. Surgical stabilization then proves to be the effective treatment of choice.

Total spondylectomy for solitary bone plasmacytoma of the lumbar spine in a young woman: a case report and review of literature.

INTRODUCTION: Solitary bone plasmacytoma (SP) is a rare diagnosis for which the primary treatment is local radiotherapy. There is no established consensus suggesting a total spondylectomy in spinal SP. MATERIALS AND METHODS: We report the case of a 43-year-old woman with solitary plasmacytoma of the lumbar spine treated with complete vertebral resection. Radiographs, CT scan and MRI showed a single osteolytic lesion of the third lumbar vertebra. Further diagnostics following recommended algorithm for tumour screening were negative. Two times, biopsy showed no histological pathologies. Due to the instability of the spine with suspicious unknown lesion, we decided to perform a dorsal lumbar approach and instrumentation with complete resection of the posterior parts to prepare for a complete resection if mandatory. Resamples were taken and the bone surfaces sealed. Consecutive findings were positive for plasma cell infiltration of the respective vertebra, however not on the first pass, but after diagnostic pathological reference. Surgery was completed by total spondylectomy. Reference histological findings with restaging and cytogenetic risk analysis confirmed a non-high-risk solitary bone plasmacytoma, and the patient was scheduled for localized radiotherapy with 40 Gy. RESULTS: Follow-up examinations (53 months) showed no local recurrence or disease progression. DISCUSSION: There is no consensus in the literature regarding appropriate surgical approach and perioperative strategies in the treatment of solitary plasmacytoma. The finding of a solitary plasmacytoma of the spine was the determining factor for our decision to perform radical surgery with subsequent radiotherapy. The rationale for the chosen approach was to minimize the risk of local recurrence and to avoid conversion into multiple myeloma. The follow-up with 53 months is limited. However, discussion remains, if radical surgery in addition to local radiotherapy could be an alternative therapeutic approach depending on paraclinical parameters, age and cytogenetic risk analysis.

Multifocal infections of the musculoskeletal system: description of a safe one-step procedure for eradication of associated spinal infections.

BACKGROUND: The aim of this study was to evaluate the clinical outcome after radical surgical treatment of multifocal infections involving the spine. METHODS: The study demonstrates a retrospective chart review of seven patients who had more than three different abscesses in the musculoskeletal system and at least one of them in the area of the spinal column. All patients had a sepsis. RESULTS: Beside different musculoskeletal abscesses four patients had a spondylodiscitis in the cervical spine segments C4/5 or C5/6. Six patients had inflammatory processes in the lumbar spine with epidural abscesses, diffuse thoracolumbar paravertebral abscesses and a spondylodiscitis in different segments. In all cases we performed a radical surgical treatment of all related inflammatory focuses. Prompt radical surgical treatment of the spine included decompression, debridement and in the cases of spondylodiscitis a fusion of the involved segments. For more than one focus at the spine, a surgical one-step procedure was performed. An antibiotic therapy was administered for six to eight weeks. In follow up examinations no signs of ongoing inflammatory processes were seen in imaging studies or laboratory tests. CONCLUSIONS: In the event of multiple abscesses of the musculoskeletal system involving the spine an early correct diagnosis and radical surgical treatment is recommended. We strongly favor a surgical single-stage procedure for treatment of multiple infections of the spine. In addition to a radical debridement and a sufficient decompression, the segmental fusion of affected areas in spondylodiscitis is essential. At the same time a surgical therapy of all other infected sites should be performed.