Nonspecific Pyogenic Spondylodiscitis: Clinical Manifestations
Object: Pyogenic vertebral osteomyelitis is of special interest to neurosurgeons because it often results in acute neurological deterioration and requires a combination of adequate surgical and conservative treatment. The aim of the current study was to evaluate the strategy of a primary surgical approach to this disease.
Methods: A group of 24 patients with the clinical and radiological signs of acute pyogenic spondylodiscitis was prospectively followed from 1998 to 2004. Of these, 20 had underlying diseases such as diabetes mellitus, chronic alcoholism, and liver cirrhosis. The main causative organism was Staphylococcus aureus. Most infections were localized in the thoracic or lumbar spine (10 cases each); 15 infections were associated with epidural abscesses. Because of a delay in diagnosis, 13 patients presented with neurological deficits on admission.
Patients with a complete or rapidly progressing neurological deficit underwent immediate surgery. In patients with minor or no deficits or in a stable neurological condition, surgery was delayed for 3 to 5 days. This group was treated with immobilization and intravenous antibiotic drugs before surgery. Surgical procedures included ventral, dorsal, and combined approaches in one- or two-stage operations. Antibiotic treatment included the use of broad-spectrum antibiotic drugs delivered intravenously for at least 10 days, followed by orally administered antibiotics for 3 months.
Twenty patients were independent on follow-up review, 15 with no or minor handicaps. Severe septicemia and multiorgan failure developed in two patients, and these two died of their disease. Major complications were mainly due to long-term antibiotic therapy.
Conclusions: Surgical treatment is the modality of choice in patients with acute spinal osteomyelitis. It is especially indicated in patients with progressive or severe neurological deficits and spinal deformity. In experienced hands, surgery is safe and offers the advantages of spinal cord decompression, immediate mobilization, and correction of spinal deformity. The decision whether an anterior or posterior approach should be used must be made on an individual basis.
Nonspecific spontaneous spinal epidural abscesses and spondylodiscitis are rare clinical conditions. Their incidence, however, appears to be on the rise, which may be attributed to various factors such as the increase in the elderly population, intravenous drug abuse, and the use of epidural catheters for pain therapy. Other important risk factors are diabetes mellitus and impaired immunocompetence (chemotherapy, human immunodeficiency virus infections, or chronic alcoholism). Because acute pyogenic vertebral osteomyelitis often results in acute neurological deterioration and requires a combination of adequate surgical and conservative treatment, it is of special importance to neurosurgeons.
In the past, antibiotic drugs were the standard (and only) method of treatment for spinal infections. With the advances in modern neurosurgical techniques for spinal instrumentation and fusion, use of these techniques should be reevaluated. Therefore, this study was designed to high light the effect and the clinical results of primary surgical treatment in cases of acute pyogenic spondylodiscitis.