[Therapy of Spondylodiscitis by Severity]. / Die schweregradorientierte Therapie der Spondylodiszitis ­ eine prospektive Betrachtung anhand von elektronisch basierten Behandlungspfaden.

Spondylodiscitis is a rare but serious infection of the spine. Recognised methods of treatment include immobilisation and systemic antibiotics. However, available data for specific and recommendations for continuing treatment are also rare. The aim of the present study is the optimisation of the therapy of spondylodiscitis using a clinical pathway that depends on a classification of spondylodiscitis. From 1 October 1998 to 31 December 2013, a classification of the severity of spondylodiscitis was established, including specific treatment recommendations. As part of the re-evaluation, the classification of severity was adapted. On this basis, electronically based clinical pathways were developed. A total of 296 cases were included. With a steadily increasing number of treatments, the mean age of the patients increased to 67.3 years. In 34.3% of these patients, spondylodiscitis developed spontaneously and 68.6% of patients did not receive treatment until the diagnosis. In the context of the specific treatment, pain intensity decreased from 6.0 to 3.1 NRS (numeric rating scale). The inflammatory values (CRP) decreased from 119.2 to 46.7 mg/dl. The time from the onset of symptoms to the surgical treatment was almost 65.6 days and has not changed significantly. Nevertheless, the time from admission to surgical treatment could be reduced to less than 3 days. The classification of patients into 3 degrees of severity of spondylodiscitis (SSC) depends on the SponDT: spondylodiscitis diagnosis and treatment. The SponDT describes vertebral destruction and the current neurological status. The severity-adapted therapy was mapped electronically and includes specific surgical care, systemic antibiotic therapy and physical therapy.

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

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

Espondilodiscitis / Spondylodiscitis

La espondilodiscitis (ED) es una infección vertebral conocida desde la Antigüedad. Su incidencia está aumentando por el incremento de la expectativa de vida y de las enfermedades debilitantes. La distribución por edad es bimodal, con afectación de los menores de 20 años y de los adultos de 50-70 años. Según su origen, se clasifican en ED piógenas, granulomatosas y parasitarias, siendo las primeras las más frecuentes y ocasionadas habitualmente por Staphylococcus aureus o Escherichia coli. La presentación clínica es insidiosa, por lo que el diagnóstico puede retrasarse, sobre todo en la ED tuberculosa. Los pacientes presentan al inicio dolor espinal de tipo inflamatorio, aunque durante el curso de la enfermedad pueden tener fiebre, astenia y déficits neurológicos como complicaciones más graves. El diagnóstico se establece basándose en datos clínicos, radiológicos, de laboratorio, microbiológicos e histopatológicos. La resonancia magnética es la técnica diagnóstica de elección. El diagnóstico diferencial se realiza, entre otros procesos, con la osteocondrosis erosiva intervertebral, tumores, la espondiloartropatía axial, la espondiloartropatía de los pacientes en hemodiálisis, cambios epifisarios de Modic tipo 1 y la neuroartropatía axial de Charcot. El tratamiento se basa en erradicar la infección con antibióticos, evitar la inestabilidad espinal con fijación vertebral y eliminar el tejido infectado con un desbridamiento amplio, obteniendo muestras para análisis etiológico (AU)

Spondylodiscitis is an infection of the spine that has been known since ancient times. Its incidence is rising, due to the increases in life expectancy and debilitating conditions. Its age distribution is bimodal, affecting persons younger than 20 years of age or persons aged 50-70 years. According to its origin, it is classified as pyogenic, granulomatous or parasitic, though the first form is the most common, usually caused by Staphylococcus aureus or Escherichia coli. The clinical presentation is insidious, resulting in a delayed diagnosis, particularly in tuberculous spondylodiscitis. The initial onset usually involves inflammatory back pain, though the disease may course with fever, asthenia and neurological deficit, these being the most severe complications. Diagnosis is based on clinical, radiological, laboratory, microbiological and histopathological data. Magnetic resonance imaging is the technique of choice for the diagnosis of spondylodiscitis. The differential diagnosis involves, among other conditions, intervertebral erosive osteochondrosis, tumour, axial spondyloarthropathy, haemodialysis spondyloarthropathy, Modic type 1 endplate changes and Charcot's axial neuroarthropathy. Treatment is based on eliminating the infection with antibiotics, preventing spinal instability with vertebral fixation, and ample debridement of infected tissue to obtain samples for analysis (AU)

Spondylodiscitis severity code: scoring system for the classification and treatment of non-specific spondylodiscitis.

INTRODUCTION: Established treatment options of spondylodiscitis, a rare but serious infection of the spine, are immobilization and systemic antibiosis. However, the available data for specific treatment recommendations are very heterogeneous. Our intention was to develop a classification of the severity of spondylodiscitis with appropriate treatment recommendations. MATERIALS AND METHODS: From 10/1/1998 until 12/31/2004, 37 cases of spondylodiscitis were examined regarding medical history, gender status, location and extent of spondylodiscitis, type and number of operations. Subsequently, a classification of six grades according to severity has been developed with specific treatment recommendations. The further evaluation of our classification and corresponding treatment modalities from 1/1/2005 to 12/31/2009 including further 132 cases, resulted in a classification of only three grades of severity (the SSC--spondylodiscitis severity code), with a follow-up until 12/31/2011. Between 01/01/2012 and 12/31/2013, a prospective study of 42 cases was carried out. Overall, 296 cases were included in the study. 26 conservatively treated cases were excluded. RESULTS AND CONCLUSION: The main localization of spondylodiscitis was the lumbar spine (55%) followed by the thoracic spine (34%). The classification of patients into 3 grades of severity depends on clinical and laboratory parameters, the morphological vertebral destruction seen in radiological examinations and the current neurological status. Therapies are adapted according to severity and they include a specific surgical management, systemic antibiotic therapy according to culture and sensitivity tests, physiotherapy and initiation of post-hospital follow-up. 40.6% of patients are associated with neurological deficits, classified as severity grade 3 and treated surgically with spinal stabilization and decompression. 46.9% of patients corresponded to severity grade 2, with concomitant vertebral destruction were dorsoventrally stabilized. The 31 patients of severity Grade 1 were treated surgically with dorsal stabilization. From 1998 to 2013, the time from the onset of symptoms to the first surgical treatment was about 69.4 days and has not changed significantly. However, the time from admission to surgical treatment had been reduced to less than 2 days. Also the time of hospitalization was reduced and we see positive effects regarding the sensation of pain. 270 patients underwent surgery. We treated 89% dorsally and 21% dorsoventrally. With the spondylodiscitis severity code, a classification of the severity of spondylodiscitis could be established and used for a severity-based treatment. In addition, specific parameters for the treatment of individual grades of severity can be determined in a clinical pathway.

[Pyogenic spondylodiscitis of the thoracic and lumbar spine : a new classification and guide for surgical decision-making]. / Pyogene Spondylodiszitis der Brust- und Lendenwirbelsäule : Eine neue Klassifikation zur Entscheidungsfindung bei der Wahl der operativen Therapie.

Despite modern diagnostic imaging options pyogenic infections of the spine are often detected tardily and therefore accompanied by a high mortality rate. To ensure an efficient and adequate therapy it is necessary to identify and treat the focus of inflammation. The recommendations for the operative strategy are still a highly controversial issue. On the other hand no classification and guidelines for surgical treatment and treatment strategies of pyogenic spinal infection have yet been published.Pyogenic spinal infections are often underestimated in frequency of occurrence and severity of symptoms. From 1994 until 2008, 269 patients suffering from an infection of the thoracic and lumbar spine were treated in the Department of Orthopedic Surgery Heidelberg and 221 patients underwent surgery. Within the scope of a clinical trial clinical aspects and therapeutic consequences of patients with pyogenic spinal infections were retrospectively investigated. Based on the study data a classification of pyogenic spinal infections of the thoracic and lumbar spine and a guide for surgical decision-making was developed.

Tuberculosis of the thoracic spine. A classification based on the selection of surgical strategies.

In spinal tuberculosis MRI can clearly demonstrate combinations of anterior and posterior lesions as well as pedicular involvement. We propose a classification system, using information provided by MRI, to help to plan the appropriate surgical treatment for patients with thoracic spinal tuberculosis. We describe a series of 47 patients, divided into four groups, based on the surgical protocol used in the management. Group A consisted of patients with anterior lesions which were stable with no kyphotic deformity, and were treated with anterior debridement and strut grafting. Group B comprised patients with global lesions, kyphosis and instability who were treated with posterior instrumentation using a closed-loop rectangle with sublaminar wires, and by anterior strut grafting. Group C were patients with anterior or global lesions as in the previous groups, but who were at a high risk for transthoracic surgery because of medical and possible anaesthetic complications. These patients had a global decompression of the cord posteriorly, the anterior portion of the cord being approached through a transpedicular route. Posterior instrumentation was with a closed-loop rectangle held by sublaminar wires. Group D comprised patients with isolated posterior lesions which required posterior decompression only. An understanding of the extent of vertebral destruction can be obtained from MRI studies. This information can be used to plan appropriate surgery.