Neurosurgical Management and Outcome Parameters in 237 Patients with Spondylodiscitis

Abstract

Surgical treatment of spondylodiscitis allows for rapid mobilization and shortens hospital stays, which makes surgical treatment the first-line therapy. We aim to describe our experiences with operative treatment on spondylodiscitis and to determine the parameters that are important in the prediction of outcomes. A retrospective review identified 237 patients who were operatively treated for spondylodiscitis in our institution between January 2010 and December 2018. Clinical data were collected through review of electronic records and relevant imaging. In all cases, contrast-enhancing MRI from the infected region of the spine was obtained. Leukocyte count and C-reactive protein concentrations (CRP) were determined in all the patients. We included 237 patients in the study, 87 female (36.7%) and 150 male (63.3%), with a mean age of 71.4 years. Mean follow-up was 31.6 months. Forty-five patients had spondylodiscitis of the cervical, 73 of the thoracic, and 119 of the lumbosacral spine. All the patients with spondylodiscitis of the cervical spine received instrumentation. In thoracic and lumbar spine decompression, surgery without instrumentation was performed in 26 patients as immediate surgery and in a further 28 patients in the early stages following admission, while 138 patients received instrumentation. Eighty-nine patients (37.6%) had concomitant infections. Infection healing occurred in 89% of patients. Favorable outcomes were noted in patients without concomitant infections, with a normalized CRP value and in patients who received antibiotic therapy for more than six weeks (p < 0.05). Unfavorable outcomes were noted in patients with high CRP, postoperative spondylodiscitis, and recurrent spondylodiscitis (p < 0.05). Application of antibiotic therapy for more than six weeks and normalized CRP showed a correlation with favorable outcomes, whereas concomitant infections showed a correlation with unfavorable outcomes. A detailed screening for concomitant infectious diseases is recommended.

Keywords: antibiotic therapy; infection; operative therapy; osteomyelitis; spinal empyema; spine; spondylodiscitis.

Figure 1

50-year-old male patient with spondylodiscitis due to an infection with methicillin-resistant Staphylococcus aureus (MRSA) of C3/4, C4/5, and C5/6, intraspinal and prevertebral empyema, and compression of the spinal cord. Corpectomy of C3, C4, C5, and C6 was performed with implantation of the expandable cage following posterior cervical and thoracic stabilization with lateral mass and pedicle screws with an occiput plate. (A). preoperative T2 weighted MRI of the cervical spine. (B,C). postoperative sagittal CT of the cervical spine shows the spinal construct. (D). postoperative T2 weighted MRI of the cervical spine shows restored alignment without signs of infection 3 months following surgery. (E). T2 weighted MRI of the cervical spine, axial view at C3 level preoperative and (F). postoperative, showing sufficient decompression following ventral decompression and stabilization.

Figure 2

44-year-old male patient with spondylodiscitis of the thoracic spine due to an infection with Mycobacterium tuberculosis. (A). preoperative T1 post-contrast MRI of the thoracic spine shows spondylodiscitis in Th 7/8 and Th 8/9. (B). postoperative T1 post-contrast of the thoracic spine shows the complete resolution of the infection 6 months following surgery. (C). postoperative X-ray of the thoracic spine shows the spinal construct with screws and rods in T7-T9. (D). Axial T1-weighted post-contrast MRI of the spine at Th7 level shows infection predominantly in ventral portion of the vertebral body. (E). T1-weighted post-contrast MRI of the spine at Th7 level 6 months following surgery shows complete resolution of the infection.

Figure 3

66-year-old male patient with spondylodiscitis and epidural empyema due to an infection with pseudomonas aeruginosa at L4/5 and L5/S1 following the stabilization of L3/4 with an intervertebral cage due to degenerative spinal canal stenosis. (A). preoperative T1 post-contrast MRI of the lumbar spine shows spondylodiscitis at L4/5 and L5/S1 with intraspinal empyema. (B). preoperative CT of the lumbar spine shows infectious degeneration of L4/5 segment. (C). postoperative lumbar spine following extension of the fusion to S1 with cage implantation in L4/5 and L5/S1. (D). postoperative sagittal X ray of the lumbar spine shows the spinal construct. (E). postoperative MRI of the lumbar spine shows the complete resolution of infection 9 months following surgery. (F). T1 weighted post-contrast of the MRI of the lumbar spine at L5 level shows intraspinal empyema. (G). Postoperative T2 weighted MRI of the spine shows infection resolution.

Figure 4

Mean CRP value in patients with favorable and non-favorable outcome. Graph shows course of CRP-value in patients with favorable (blue line) and no- favorable outcome (orange line). Threshold of CRP value of 5 mg/L, which is considered to be physiologic, is presented with dotted line. Patients with unfavorable outcome had higher initial CRP values and higher values of CRP at the time of switch to oral antibiotics, compared to the patients with favorable outcome.