A comparative perspective on brucellar, pyogenic, and tuberculous spondylodiscitis.

OBJECTIVE: Non-specific features of spondylodiscitis lead to a delay and challenge in the diagnosis/differential diagnosis/treatment processes, and thus, serious complications may arise. This study aims to compare brucellar, pyogenic, and tuberculous types of spondylodiscitis, considering their demographic, clinical, and laboratory differences. This may provide more rapid management and good outcomes. PATIENTS AND METHODS: A total of 131 patients with infectious spondylodiscitis were included in the study. The patients were divided into brucellar (n=63), pyogenic (n=53), and tuberculous (n=15) types of spondylodiscitis and compared for demographic, clinical, laboratory, and imaging features. RESULTS: Tuberculous spondylodiscitis had higher scores for weight loss, painless palpation, thoracic spine involvement, and psoas abscess formation than other spondylodiscitis. Also, tuberculous spondylodiscitis had higher rates of neurologic deficit and lower rates of lumbar involvement than brucellar spondylodiscitis. Pyogenic spondylodiscitis is more likely to occur in patients who have a history of spine surgery compared to other forms of spondylodiscitis. Also, pyogenic spondylodiscitis had higher rates of fever, erythema, paraspinal abscess, white blood cell (WBC), and erythrocyte sedimentation rate (ESR) than brucellar spondylodiscitis. On the other hand, brucellar spondylodiscitis had higher rates of rural living and sweating than pyogenic spondylodiscitis. CONCLUSIONS: Weight loss, painless palpation, involved thoracic spine, psoas abscess, and neurologic deficit are symptoms favoring tuberculous spondylodiscitis. History of spine surgery, high fever, skin erythema, and paraspinal abscess are findings in favor of pyogenic spondylodiscitis. Rural living, sweating, and involved lumbar spine are symptoms that indicate brucellar spondylodiscitis. These symptoms can be used to distinguish the types of spondylodiscitis.

Bacterial and Viral Infectious Disease of the Spine.

Spinal infections are a diverse group of diseases affecting different compartments of the spine with variable clinical and imaging presentations. Diagnosis of spinal infections is based on a combination of clinical features, laboratory markers, and imaging studies. Imaging plays a pivotal role in the diagnosis and management of spinal infections. The characteristic imaging manifestations of bacterial and viral infections in the spine are discussed with key teaching points emphasized.

Differentiation of Native Vertebral Osteomyelitis: A Comprehensive Review of Imaging Techniques and Future Applications.

Native vertebral osteomyelitis, also termed spondylodiscitis, is an antibiotic-resistant disease that requires long-term treatment. Without proper treatment, NVO can lead to severe nerve damage or even death. Therefore, it is important to accurately diagnose the cause of NVO, especially in spontaneous cases. Infectious NVO is characterized by the involvement of 2 adjacent vertebrae and intervertebral discs, and common infectious agents include Staphylococcus aureus, Mycobacterium tuberculosis, Brucella abortus, and fungi. Clinical symptoms are generally nonspecific, and early diagnosis and appropriate treatment can prevent irreversible sequelae. Advances in pathologic histologic imaging have led physicians to look more forward to being able to differentiate between tuberculous and septic spinal discitis. Therefore, research in identifying and differentiating the imaging features of these 4 common NVOs is essential. Due to the diagnostic difficulties, clinical and radiologic diagnosis is the mainstay of provisional diagnosis. With the advent of the big data era and the emergence of convolutional neural network algorithms for deep learning, the application of artificial intelligence (AI) technology in orthopedic imaging diagnosis has gradually increased. AI can assist physicians in imaging review, effectively reduce the workload of physicians, and improve diagnostic accuracy. Therefore, it is necessary to present the latest clinical research on NVO and the outlook for future AI applications.

Drug eluting bioactive glass ceramics for fusion in spondylodiscitis: a pilot study.

Retrospective observational study. To determine the efficacy and safety of bioactive glass ceramics mixed with autograft in the treatment of spondylodiscitis. Thirty-four patients with spondylodiscitis underwent surgery using autologous bone graft augmented by antibiotic loaded bioactive glass ceramic granules. Twenty-five patients aging 6 to 77, completed 1-year follow-up. The lumbosacral junction was affected in 3, lumbar spine in 13, one each in the dorso-lumbar junction and sacrum, and 7 dorsal spines. The organism isolated was Mycobacterium tuberculosis in 15, Methicillin sensitive Staphylococcus aureus (MSSA) in 4, Pseudomonas aeruginosa in 4, Klebsiella pneumoniae in one, Burkholderia pseudomallei in 1, and mixed infections in 2. All patients had appropriate antibiotic therapy based on culture and sensitivity. Clinical and radiological evaluation of all the patients was done at 6 weeks, 3 months, 6 months, and 12 months after the surgery. Twenty-three patients improved clinically and showed radiographic fusion between 6 and 9 months. The patient with Burkholderia infection died due to fulminant septicemia with multi organ failure while another patient died at 9 months due to an unrelated cardiac event. The mean Visual Analogue Score (VAS) at the end of 1-year was 2 with radiological evidence of fusion in all patients. There were no re-infections or discharging wounds, and the 30-day re-admission rate was 0. Bioactive glass ceramics is a safe and effective graft expander in cases of spondylodiscitis. The absorption of antibiotics into the ceramic appears to help the elimination of infection.

Evaluation of the 2023 Duke-ISCVID and 2023 Duke-ESC Clinical Criteria for the Diagnosis of Infective Endocarditis in a Multicenter Cohort of Patients With Staphylococcus aureus Bacteremia.

BACKGROUND: The Duke criteria for infective endocarditis (IE) diagnosis underwent revisions in 2023 by the European Society of Cardiology (ESC) and the International Society for Cardiovascular Infectious Diseases (ISCVID). This study aims to assess the diagnostic accuracy of these criteria, focusing on patients with Staphylococcus aureus bacteremia (SAB). METHODS: This Swiss multicenter study conducted between 2014 and 2023 pooled data from three cohorts. It evaluated the performance of each iteration of the Duke criteria by assessing the degree of concordance between definite S. aureus IE (SAIE) and the diagnoses made by the Endocarditis Team (2018-23) or IE expert clinicians (2014-17). RESULTS: Among 1344 SAB episodes analyzed, 486 (36%) were identified as cases of SAIE. The 2023 Duke-ISCVID and 2023 Duke-ESC criteria demonstrated improved sensitivity for SAIE diagnosis (81% and 82%, respectively) compared to the 2015 Duke-ESC criteria (75%). However, the new criteria exhibited reduced specificity for SAIE (96% for both) compared to the 2015 criteria (99%). Spondylodiscitis was more prevalent among patients with SAIE compared to those with SAB alone (10% vs 7%, P = .026). However, when patients meeting the minor 2015 Duke-ESC vascular criterion were excluded, the incidence of spondylodiscitis was similar between SAIE and SAB patients (6% vs 5%, P = .461). CONCLUSIONS: The 2023 Duke-ISCVID and 2023 Duke-ESC clinical criteria show improved sensitivity for SAIE diagnosis compared to 2015 Duke-ESC criteria. However, this increase in sensitivity comes at the expense of reduced specificity. Future research should aim at evaluating the impact of each component introduced within these criteria.

Ascorbic acid deficiency amongst spondylodiscitis patients.

BACKGROUND: Spondylodiscitis can be a disabling and life-threatening infection. Ascorbic Acid is crucial for neutrophil function and collagen formation. Its association and clinical relevance in spondylodiscitis has not been previously examined. AIMS: To determine the prevalence, characteristics, and clinical outcomes of spondylodiscitis patients with Ascorbic Acid deficiency. METHODS: Sixty-eight consecutive patients admitted with spondylodiscitis, between December 2021 and August 2023 were included. Clinical characteristics, Ascorbic Acid levels and clinical outcomes were evaluated. RESULTS: Thirty-seven patients had Ascorbic Acid levels taken during admission. The median initial Ascorbic Acid level was 15 µmol/L with an IQR 6.5-27 µmol/L. Depletion defined as <28 µmol/L was present in 78% of patients. Deficiency defined as ≤11 µmol/L was present in and 46% of patients. Patients with depletion were more likely to require Intensive Care Admission (absolute risk increase = 24.1%; 2.6%-45.7%). Fifteen patients had repeat serum levels taken during admission with median increase of 17 µmol/L and an IQR 0-26 µmol/L. Patients that received supplementation had a significantly greater increase in Ascorbic Acid levels compared with those that did not receive supplementation (P = 0.002). CONCLUSION: Ascorbic acid deficiency is highly prevalent amongst spondylodiscitis patients. Depletion was associated with worse outcomes. Replacement significantly increased serum levels in comparison to standard hospital diet. The clinical significance of replacement remains to be evaluated.

Induction of cervical disc degeneration and discogenic pain by low concentration Propionibacterium acnes infection: an in vivo animal study.

BACKGROUND: Although cervical intervertebral disc (IVD) degeneration is closely associated with neck pain, its cause remains unclear. In this study, an animal model of cervical disc degeneration and discogenic neck pain induced by a low concentration of Propionibacterium acnes (P. acnes-L) is investigated to explore the possible mechanisms of cervical discogenic pain. METHODS: Cervical IVD degeneration and discitis was induced in 8-week-old male rats in C3-C6 IVDs through the anterior intervertebral puncture with intradiscal injections of low and high concentrations of P. acnes (P. acnes-L, n = 20 and P. acnes-H, n = 15) or Staphylococcus aureus (S. aureus, n = 15), compared to control (injection with PBS, n = 20). The structural changes in the cervical IVD using micro-CT, histological evaluation, and gene expression assays after MRI scans at 2 and 6 weeks post-modeling. The P. acnes-L induced IVD degeneration model was assessed for cervical spine MRI, histological degeneration, pain-like behaviors (guarding behavior and forepaw von Frey), nerve fiber growth in the IVD endplate region, and DRG TNF-α and CGRP. RESULTS: IVD injection with P. acnes-L induced IVD degeneration with decreased IVD height and MRI T2 values. IVD injection with P. acnes-H and S. aureus both lead to discitis-like changes on T2-weighted MRI, trabecular bone remodeling on micro-CT, and osseous fusion after damage in the cartilage endplate adjacent to the injected IVD. Eventually, rats in the P. acnes-L group exhibited significant nociceptive hypersensitivity, nerve fiber ingrowth was observed in the IVD endplate region, inflammatory activity in the DRG was significantly increased compared to the control group, and the expression of the pain neurotransmitter CGRP was significantly upregulated. CONCLUSION: P. acnes-L was validated to induce cervical IVD degeneration and discogenic pain phenotype, while P. acnes-H induced was identified to resemble septic discitis comparable to those caused by S. aureus infection.

The importance of the bacterial spectrum in the clinical diagnostics and management of patients with spontaneous pyogenic spondylodiscitis and isolated spinal epidural empyema: a 20-year cohort study at a single spine center.

BACKGROUND: Personalized clinical management of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) is challenging due to limited evidence of microbiologic findings and their clinical impact during the clinical course of the disease. We aimed to characterize clinico-microbiological and imaging phenotypes of SD and ISEE to provide useful insights that could improve outcomes and potentially modify guidelines. METHODS: We performed chart review and collected data on the following parameters: bacterial antibiogram-resistogram, type of primary spinal infection, location of spinal infection, source of infection, method of detection, clinical complications (sepsis, septic embolism, and endocarditis), length of hospital and intensive care unit (ICU) stay, relapse rate, and disease-related mortality in patients with proven pyogenic SD and ISEE treated surgically in a university hospital in Germany between 2002 and 2022. RESULTS: We included data from 187 patients (125 SD, 66.8% and 62 ISEE, 33.2%). Gram-positive bacteria (GPB) were overall more frequently detected than gram-negative bacteria (GNB) (GPB: 162, 86.6% vs. GNB: 25, 13.4%, p < 0.001). Infective endocarditis was caused only by GPB (GPB: 23, 16.5% vs. GNB: 0, 0.0%, p = 0.046). Methicillin-susceptible Staphylococcus aureus was the most frequently isolated strain (MSSA: n = 100, 53.5%), occurred more frequently in the cervical spine compared to other bacteria (OB) (MSSA: 41, 41.0% vs. OB: 18, 20.7%, p = 0.004) and was most frequently detected in patients with skin infection as the primary source of infection (MSSA: 26, 40.6% vs. OB: 11, 16.7%, p = 0.002). Streptococcus spp. and Enterococcus spp. (SE: n = 31, 16.6%) were more often regarded as the cause of endocarditis (SE: 8, 27.6% vs. OB: 15, 11.4%, p = 0.037) and were less frequently detected in intraoperative specimens (SE: 19, 61.3% vs. OB: 138, 88.5%, p < 0.001). Enterobacterales (E: n = 20, 10.7%) were identified more frequently in urinary tract infections (E: 9, 50.0% vs. OB: 4, 3.6%, p < 0.001). Coagulase-negative Staphylococci (CoNS: n = 20, 10.7%) were characterized by a lower prevalence of sepsis (CoNS: 4, 20.0% vs. OB: 90, 53.9%, p = 0.004) and were more frequently detected in intraoperative specimens (CoNS: 20, 100. 0% vs. OB: 137, 82.0%, p = 0.048). Moreover, CoNS-associated cases showed a shorter length of ICU stay (CoNS: 2 [1-18] days vs. OB: 6 [1-53] days, median [interquartile range], p = 0.037), and occurred more frequently due to foreign body-associated infections (CoNS: 8, 61.5% vs. OB: 15, 12.8%, p = 0.008). The presence of methicillin-resistant Staphylococcus aureus (MRSA) prolonged hospital stay by 56 [24-58] days and ICU stay by 16 [1-44] days, whereas patients with Pseudomonas aeruginosa spent only 20 [18-29] days in the hospital and no day in the ICU 0 [0-5] days. CONCLUSIONS: Our retrospective cohort study identified distinct bacterial-specific manifestations in pyogenic SD and ISEE regarding clinical course, neuroanatomic targets, method of pathogen detection, and sources of infection. The clinico-microbiological patterns varied depending on the specific pathogens.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice.

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines). PREOPERATIVE PATIENTS' INFORMATION: Each patient must be informed concerning the risks associated with POP surgery (EO). HEMORRHAGE, HEMATOMA: Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO). BLADDER INJURY: When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO). URETER INJURY: After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO). RECTAL INJURY: Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO). VAGINAL WALL INJURY: After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO). MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS): Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient. BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM: Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO). URINARY RETENTION: Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO). POSTOPERATIVE PAIN: Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO). POSTOPERATIVE DYSPAREUNIA: When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO). VAGINAL MESH EXPOSURE: To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO). SUTURE THREAD VAGINAL EXPOSURE: For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed. BLADDER AND URETERAL MESH EXPOSURE: When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Pyogenic spondylodiscitis in HIV-positive patients under antiretroviral therapy: A case series.

Background: The incidence of pyogenic spondylodiscitis has been increasing in countries of Europe and North America, probably due to an increasing number of persons with risk factors for this infection. It is unclear whether HIV infection in the era of antiretroviral therapy (ART) increases the risk for spondylodiscitis. Method: We present 7 cases of pyogenic spondylodiscitis of the cervical, thoracic, and lumbar spine in six individuals living with HIV under ART with suppressed viral load. Results: All patients presented with severe non-radicular pain and elevated inflammatory markers. Diagnosis was confirmed by magnetic resonance imaging (MRI) scan and isolation of the pathogen. Staphylococcus aureus was the causative pathogen in five patients. One patient suffered from an infection with Klebsiella pneumoniae followed by a mixed infection with Cutibacterium acnes and Bacillus circulans 18 months later. All patients needed surgical intervention, and the mean duration of antibiotic treatment was 17 weeks (range 12-26). Five patients recovered fully, including two persons who also suffered from endocarditis. One patient died from multi-organ failure. Conclusion: Spondylodiscitis may be seen more frequently in persons living with HIV as they grow older and suffer from comorbidities which put them at risk for this infection. HIV physicians should be aware of the infection and its risk factors.

Spondylodiscitis instrumented fusion, a prospective case series on a standardized neurosurgical protocol with long term follow up.

PURPOSE: To investigate the fusion construct properties, construct length, intervertebral prosthesis (IVP) selection, bone grafting methods, complications management, and follow-up outcomes of spondylodiscitis fusion. METHOD: This case series was conducted in Al-Zahra University referral hospital from March 2016 to November 2021. All the surgery-eligible patients were enrolled. Those who did not participate or failed the neurosurgical intervention were excluded. A unified neurosurgical protocol was defined. After operation and follow-up, all variables were documented. IBM SPSS v.26 was used for data analysis. P-value ≤ 0.05 was considered significant. RESULT: Ninety-two patients were reviewed in the final analysis with 65.2 % males. The mean age was 55.07 ± 14.22 years old. The most frequent level of pathology and surgery was the lumbar spine (48.9 %). Short and long constructs were almost equally used (57.6 and 42.4 %, respectively). Bone graft mixture was the dominant IVP (75 %). The most frequent persistent postoperative symptom was back pain (55.4 %), while the neurological deficits resolution rate was 76.7 %. The fusion rate was 92.3 %. Proximal junctional kyphosis incidence was 16.3 % and had a significant association with on-admission neurological symptoms, thoracic and thoracolumbar junction involvements (p < 0.05). Follow-up Oswestry disability index scores showed 44.6 % of the patients had mild or no functional disabilities. Advanced age, On-admission deficits, comorbidities, titanium cages, and poor fusion status were associated with poor functional outcomes and higher mortality rates (P < 0.05). CONCLUSION: The introduced neurosurgical protocol could effectively achieve acceptable SD treatment, spine stabilization, and fusion with low long-term surgical complications. Autologous bone graft mixture in comparison to titanium cages showed a higher fusion rate with a lower mortality rate. Patients with older age, neurological symptoms, and comorbidities are expected to experience less favorable clinical outcomes.

Candida spondylodiscitis: a systematic review and meta-analysis of seventy two studies.

OBJECTIVES: Knowledge of Candida spondylodiscitis is limited to case reports and smaller case series. Controversy remains on the most effective diagnostical and therapeutical steps once Candida is suspected. This systematic review summarized all cases of Candida spondylodiscitis reported to date concerning baseline demographics, symptoms, treatment, and prognostic factors. METHODS: A PRISMA-based search of PubMed, Web of Science, Embase, Scopus, and OVID Medline was performed from database inception to November 30, 2022. Reported cases of Candida spondylodiscitis were included regardless of Candida strain or spinal levels involved. Based on these criteria, 656 studies were analyzed and 72 included for analysis. Kaplan-Meier curves, Fisher's exact, and Wilcoxon's rank sum tests were performed. RESULTS: In total, 89 patients (67% males) treated for Candida spondylodiscitis were included. Median age was 61 years, 23% were immunocompromised, and 15% IV drug users. Median length of antifungal treatment was six months, and fluconazole (68%) most commonly used. Thirteen percent underwent debridement, 34% discectomy with and 21% without additional instrumentation. Median follow-up was 12 months. The two year survivorship free of death was 80%. The two year survivorship free of revision was 94%. Younger age (p = 0.042) and longer length of antifungal treatment (p = 0.061) were predictive of survival. CONCLUSION: Most patients affected by Candida spondylodiscitis were males in their sixties, with one in four being immunocompromised. While one in five patients died within two years of diagnosis, younger age and prolonged antifungal treatment might play a protective role.

Management of Postoperative Discitis with Debridement and Novel Technique of Local Antibiotic Instillation: Functional Outcomes from a Resource-Limited Setting.

BACKGROUND: Patients in low- and middle-income countries (LMICs) have substantial treatment abandonment and non-adherence with outpatient oral medications. This work sought to investigate outcomes of postoperative discitis treated with debridement and a novel technique focused on reducing outpatient antibiotic requirement in an LMIC setting. METHODS: This study, conducted and reported following STROBE guidelines, reviewed outcomes of all patients with postoperative discitis who had been debrided by 1 neurosurgeon in a resource-limited setting during 2008-2020. Patients had undergone single-level L4-L5 or L5-S1 discectomy elsewhere, later developing magnetic resonance imaging-confirmed discitis. After non-response or deterioration following intravenous antibiotics, patients underwent early debridement, followed by in-patient antibiotic instillation into disc space for 2 weeks via drain. Study outcomes were modified Kirkaldy-Willis Grade, Japan Orthopaedic Association (JOA) score, and visual analog scale (VAS) score, all assessed at 1 year. RESULTS: Twelve patients were included, 10 male and 2 female, with median age of 46 (IQR 3.5) years. Debridement was done after median 82.5 (IQR 35) days and took median time of 105 (IQR 17.5) minutes. VAS scores (mean ± SD) decreased from 9.25 ± 0.75 preoperatively to 0.67 ± 0.89 1 year postoperatively (mean difference 8.58, 95% CI 8.01-9.15, P < 0.001). JOA scores (mean ± SD) improved from 4.5 ± 2.94 to 26.42 ± 1.31 1 year postoperatively (mean difference 21.92, 95% CI 20.57-23.26, P < 0.001). Kirkaldy-Willis grade was excellent in 6 (50%) patients, good in 5 (41.7%), and fair in 1 (8.3%). Patients became ambulatory within 2 weeks, with no major complications during 4.15 (IQR 3.45) years of median follow-up. CONCLUSIONS: In LMICs, patients with medically refractory postoperative discitis potentially have good outcomes after debridement plus 2-week local antibiotic instillation.

Abiotrophia defectiva triple threat: A rare case of infective spondylodiscitis, endocarditis, and brain abscess.

Abiotrophia defectiva is a pathogen of the oral, gastrointestinal, and urinary tracts that can cause significant systemic disease with uniquely negative blood cultures depending on the growth medium. Prior cases note possible seeding from relatively common procedures such as routine dental work and prostate biopsies, however case literature describes prior infectious complications to include infective endocarditis, brain abscess formation, and spondylodiscitis. While prior cases describe some aspects of these presentations, we highlight a case of a 64-year-old male who presented to the emergency department (ED) f5or acute onset of low back pain with fever symptoms four days after an outpatient transrectal ultrasound-guided needle biopsy of the prostate, with a prior dental extraction described four weeks prior to arrival. Findings on initial ED presentation and subsequent hospitalization revealed infective spondylodiscitis, endocarditis, and brain abscess formation. This is the only cases noted in literature with all three infection locations with dual risk factors of dental and prostate procedures prior to symptom onset. This case highlights the multifocal illness that can complicate Abiotrophia defectiva infections, and the importance of thorough ED evaluation and multiservice approach for consultation and treatment.

Treatment of Spinal Infections.

The treatment of spinal infections is not well defined, and a cursory review of the literature can lead to conflicting treatment strategies. To add to the complexity, infections can include primary infection of the spine, infection secondary to another primary source, and postoperative infections including epidural abscesses, discitis, osteomyelitis, paraspinal soft-tissue infections, or any combination. Furthermore, differing opinions often exist within the medical and surgical communities regarding the outcomes and effectiveness of varying treatment strategies. Given the paucity of defined treatment protocols and long-term follow-up, it is important to develop multidisciplinary treatment teams and treatment strategies. This, along with defined protocols for the treatment of varying infections, can provide the data needed for improved treatment of spinal infections.

Espondilodiscitis multifocal y meningoencefalitis por Staphylococcus aureus en un paciente inmunocomprometido / Multifocal spondylodiscitis and meningoencephalitis due to Staphylococcus aureus in an immunocompromised patient

Spondylodiscitis is a rare diagnosis, but its incidence has increased in recent years. It represents 3-5% of osteomyelitis, and the multifocal affliction is rare as it occurs in 4-8% of all spondylodiscitis. The occurrence of meningoencephalitis associated with spondylodiscitis is also a rare association. We present the case of a 54-year-old woman diagnosed with multifocal spondylodiscitis complicated with meningoencephalitis and intracanal and paravertebral abscess with identification in blood cultures of Staphylococcus aureus. Immunosuppression with infliximab was identified as a risk factor. The patient underwent targeted antibiotic therapy, opting for the conservative strategy due to the surgical risk. There was a positive evolution with imaging resolution of the intracanal abscess. This case is of particular importance due to its rarity of frequency and considering the etiological agent and the low frequency of this infection in patients under anti-TNF-alpha therapy. (AU)

La espondilodiscitis es un diagnóstico poco frecuente, pero su incidencia ha aumentado en los últimos años. Representa el 3-5% de las osteomielitis, y la afección multifocal es rara, ya que se da en el 4-8% de todas las espondilodiscitis. La aparición de meningoencefalitis asociada a espondilodiscitis también es una asociación poco frecuente. Presentamos el caso de una mujer de 54 años diagnosticada de espondilodiscitis multifocal complicada con meningoencefalitis y absceso intracanal y paravertebral con identificación en hemocultivos de Staphylococcus aureus. Se identificó como factor de riesgo la inmunosupresión con infliximab. La paciente fue sometida a antibioterapia dirigida, optándose por la estrategia conservadora debido al riesgo quirúrgico. Hubo una evolución positiva con resolución imagenológica del absceso intracanal. Este caso es de especial importancia por su escasa frecuencia y teniendo en cuenta el agente etiológico y la baja frecuencia de esta infección en pacientes bajo terapia anti-TNF-alfa. (AU)