Aim. Pyogenic spondylodiscitis remains a therapeutic challenge, as demonstrated by divergent treatment guidelines. The combination of moxifloxacin and rifampicin may be an attractive treatment option for cases caused by staphylococci; however, previous studies have reported a reduction in plasma concentrations of moxifloxacin when co-administered with rifampicin. The magnitude of this reduction in spinal tissues is not known. We aimed to investigate the interaction of rifampicin on moxifloxacin tissue concentrations in vertebral cancellous bone, intervertebral disc and subcutaneous adipose tissue in steady-state conditions using microdialysis in a porcine model. Method. Twenty female pigs were randomized into two groups of ten pigs: Group A received moxifloxacin 400 mg orally once daily for three days preoperatively. Group B received moxifloxacin 400 mg orally for three days preoperatively combined with rifampicin 450 mg twice daily for seven days preoperatively. Measurements were obtained from plasma, vertebral cancellous bone, intervertebral disc and subcutaneous adipose tissue for 24 h. Microdialysis was applied for sampling in solid tissues. Results. Co-administration of moxifloxacin and rifampicin demonstrated a reduction of free moxifloxacin concentrations in spinal tissues. The peak drug concentration (C. max. ) and the area under the concentration-time curve (AUC. 0–24. ) in all tissue compartments decreased in the range of 66–79% and 65–76%, respectively. Conclusions. Using microdialysis, we demonstrated a significant reduction of moxifloxacin C. max. and AUC. 0–24. in the spinal tissues when co-administered with rifampicin. Further studies are warranted to understand the clinical implications of this finding for the treatment of pyogenic spondylodiscitis

Aim. Empiric antibiotic therapy for suspected pyogenic spondylodiscitis (SD) should be initiated immediately with severely ill patients and may also be necessary for culture-negative SD. The aim of this study was to infer an appropriate empiric antibiotic regimen by analyzing the antimicrobial susceptibility of isolated pathogens from microbiologically proven pyogenic spondylodiscitis. Method. We performed a retrospective review of adult patients with clinically proven SD treated at our level 1 trauma center between 2013 and 2020. Demographic data, radiologic findings, and treatment modalities were evaluated. The appropriateness of empiric antibiotic regimens was assessed based on the antibiograms of the isolated pathogens. Anamneses were used to distinguish between community-acquired (CA) and healthcare-associated (HA) pathogens, which included cases that had a hospital stay or invasive intervention in the past 6 months. Results. A total of 155 patients (male: N=88; female: N=67; mean age 66.1 ± 12.4 years) with SD were identified. In n= 74 (47.7%) cases, the infections were associated with the healthcare system (HA). N=34 (21.9%) patients suffered from sepsis. The lumbar spine was involved in 47.1% of the cases, the thoracic spine in 37.3%, and the cervical spine in 7.8%. In 7.8% of the cases, SD occurred in multiple spinal segments. N=96 (62.0%) patients were treated surgically. The mean hospital stay was 36.4 ± 36.3 days. Antibiograms of n=45 patients (HA: N=22; CA: N=23) could be retrospectively evaluated: The most frequently identified pathogens were Staphylococcus aureus (46.7%), Coagulase-negative Staphylococci (17.8%), Enterobacteriaceae (15.6%) and Streptococcus species (15.6%). Overall, 82.2% (HA: 68.2%; CA: 95.5%) of the isolated pathogens were sensitive to piperacillin/tazobactam, 77.8% (HA: 81.8%; CA: 72.2%) to vancomycin, 64.4% (HA: 68.2%; CA: 59.1%) to clindamycin, and 55.6% (HA: 36.4%; CA: 72.7%) to ceftriaxone. To a combination of vancomycin plus meropenem 97.8% of pathogens were sensitive (HA: 95.5%; CA: 100.0%), to vancomycin plus ciprofloxacin 91.1% (HA: 86.4%; CA: 95.7%), and to vancomycin plus cefotaxime 93.3% (HA: 90.9%; CA: 95.7%). In 14 cases, empiric antibiosis was adjusted based on the results of the antibiogram. Conclusions. Antibiotic resistance of CA SD pathogens differed significantly from HA SD. The identification of the pathogen and the analysis of its susceptibility guides the antibiotic therapy. Vancomycin in combination with a carbapenem, broad-spectrum cephalosporin, or fluoroquinolone may be appropriate for empiric treatment of HA SD

To investigate clinical outcome scores in surgically treated patients with either spontaneous or postoperative pyogenic spondylodiscitis after 3, 12 and 24 month. 70 consecutive patients (mean age 64y; male n=33 female n=27) underwent surgical treatment due to pyogenic spondylodiscitis with or without epidural abscess at our department from 2011 to 2013. We performed either microsurgical debridement or debridement in combination with ventral support employing dorsally instrumented spondylodesis followed by bracing and antibiotic therapy up to 12 weeks. European life quality score (EQ-5D), Oswestry disability index (ODI) and visual analogue scale for pain (VAS) were recorded 3, 12 and 24 month after surgery. Length of hospital stay (LOS) was 25,3 days. The Mean time to presentation at our spine center and diagnosis was 3,8 weeks. Distribution of inflammation was lumbar in 66 (94%) and thoracic in 4 (6%) patients. Thirtyfour patients (49%) had isolated spondylodiscitis (SD). Epidural abscess (ED) was found in 26 patients (37%). Ten patients (14%) showed a combination of SD and ED. SD or ED were predominantly found after previous surgery at the same or contiguous level 38 (54%). Nine patients (13%) suffered from ED or SD after previous lumbar epidural steroid injections (LESI). Spontaneous idiopathic inflammation was found only in 13 cases (19%). Standardized follow-up (FU) protocol was scheduled at 3, 12, and 24 month. FU rate was 60%. Healing of the inflammation was the rule. In our study cumulative EQ-5D increased from 0.47 to 0,80. ODI decreased from 41.1 to 24.3 and VAS concerning back pain decreased from 58.4 to 22.6 VAS according sciatica decreased from 46.8 to 20.5. Due to an increasing number of spine surgeries and spinal interventions as well as the increasing age and morbidity of patients, spinal surgeons have to deal more often with the diagnosis pyogenic spondylodiscitis. Standardized conservative or radical surgical treatment strategies in order to achieve good results according to patients life quality are gaining more importance

Purpose of the study: Surgical strategy for the treatment of pyogenic spondylodiscitis remains a controversial issue, mainly because of the low incidence. This retrospective review was undertaken to clarify current practices. Material and methods: Nineteen patients (11 male, 6 female)with pyogenic spondylodiscitis underwent surgery from 2003 to 208. Mean age at surgery was 62.7 years (41–100). The localisation was cervical (n=6), thoracic (n=8) and lumbar (n=3). Motor deficit was present preoperatively in 13 patients. There were no cases of complete paralysis. The indication for surgery was aggravation of the neurological deficit in 14 patients and kyphosic deformity in three. The release was achieved via an anterior access for the cervical cases and via a posterior access for the thoracic and lumbar cases. The circumferential procedure achieved complete bilateral arthrectomy. In all cases the instrumented fusion was followed by postoperative immobilisation for three months. Antibiotics were also given for three months. Functional and radiographic outcome were assessed at last follow-up. Results: Mean follow-up was months (12–26 months). There were no clinical or biological signs of recurrent infection despite implantation of osteosynthesis material. Irrespective of the delay to treatment, the 13 patients with a preoperative deficit presented signs of recovery. Eight of them recovered completely and the five others had a motor deficit rated at 4/5. Radiographically, there were no fusion failures at last follow-up. Two patients had revision surgery: one for recurrent tetraparesia due to a postoperative epidural haematoma, the other to achieve impaction of the graft in the vertebral body. Discussion: – This series emphasises the clinical impact of surgical treatment of pyogenic spondylodiscitis. Surgery enables a certain degree of neurological recover achieved by wide decompression. It enables bone fusion despite instrumentation in this complex septic situation

Study design: Retrospective clinical study. Objective: To assess the results of spondylodiscitis treated by surgery. To compare debridement and instrumentation with debridement without instrumentation. Methods: Between February 1989 and February 2008, 29 patients with a diagnosis of spondylodiscitis underwent surgery. The mean age at the time of surgery was 57 years (range, 12–84). The average follow-up period was 8.4 years (range, 1–20). Pyogenic spondylodiscitis was diagnosed in 17 cases and tuberculous spondilodyscitis in 12 cases. The results of 14 patients treated by debridement and instrumentation (Group I) were compared with 15 patients who received debridement without instrumentation (GroupII). The saggital angle, loss of correction and clinical results were compared. Results: The clinical presentation was: intractable pain 20.7%, severe pain irradiating lower limbs 20.7%, pain and neurologic deficit 44.8%, pain and kyphotic deformity 3.4%, pain and psoas abscess 10.3%. Preoperative punction CT-guided was performed in 51.7% of patients. It was positive in 26.7% of those patients. Blood cultures were positive in 29.4% and intra-operative culture was positive in 53% of the pyogenic spondylodiscitis. Staphylococcus aureus was the most common organism. The averaged onset of symptoms-surgery period was 6.75 months in tuberculous spondylodiscitis and 3.2 months in pyogenic spondylodiscitis. Double-level spondylodiscitis was observed in 41.4%. The spinal region most frequently affected by spondylodiscitis was the thoracolumbar and lumbar spine in 66% of cases. All of the patients with incomplete neurologic impairment showed improvement after surgery. There were no recurrences of infection. There was a statistically significant difference (p=0.011) in the loss of correction of saggital angle: more loss of correction in Group II 7.07° (range, 0°–17°) than in Group I 1.8° (range, 0°–5°). The saggital angle preoperative/postoperative/3 months postop/6 months postop/12 months postop/ Final was: 14.42° /1.96° /2.75° /2.83° /2.92° /3.75° (means) in Group I. −7.57°/–8.43°/ −3.21°/ −1.71°/ −1.93°/ −1.36° in Group II (in this group, there was a significant loss of correction between inmediate postoperative-3 months postop and 3 months postop-6 months postop). There were statistically significant differences in operative time and in blood loss (more in Group I). The preoperative Visual Analogic Scale score averaged 9 in Group I and 9 in Group II and improved to 2.4 and 2.33 after surgery, respectively. Conclusion: Instrumentation in spondylodiscitis does not increase the recurrence of infection, and additionally it stabilized the affected segment maintaining the saggital angle. Instrumentation is recommended in tho-racolumbar spine, kyphotic deformity and in multiple-level spondylodiscitis

Summary. Pyogenic spondylodiscitis is an uncommon but severe spinal infection. In majority of cases treatment is based on intravenous antibiotics and rigid brace immobilization. Posterior percutaneous spinal instrumentation is a safe alternative procedure in relieving pain, preventing deformity and neurological compromise. Introduction. Pyogenic spondylodiscitis (PS) is an uncommon but severe spinal infection. Patients affected by a non-complicated PS and treatment is based on intravenous antibiotics and rigid brace immobilization with a thoracolumbosacral orthosis (TLSO) suffices in most cases in relieving pain, preventing deformity and neurological compromise. Since January 2010 we started offering patients percutaneous posterior screw-rod instrumentation as alternative approach to TLSO immobilization. The aim of this study was to evaluate safety and effectiveness of posterior percutaneous spinal instrumentation for single level lower thoracic (T9-T12) or lumbar pyogenic spondylodiscitis. Materials and Methods. Retrospective cohort analysis on 27 patients diagnosed with PS who were offered to choose between 24/7 TLSO rigid bracing for 3 to 4 months and posterior percutaneous screw-rod instrumentation bridging the infection level followed by soft bracing for 4 weeks after surgery. All patients underwent antibiotic therapy. Fifteen patients chose conservative treatment, 12 patients chose surgical treatment. Patients were seen at 1, 3, 6, 9 months after diagnosis. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and complete blood count were measured at each follow-up visit. Segmental kyphosis was measured at diagnosis and at 9 months. VAS, SF-12, and EQ-5D questionnaires were recorded at each follow-up visit. Baseline groups’ demographic characteristics were assessed using independent sample t-tests for continuous variables and χ2 tests for frequency variables. Results. Complete healing was achieved in all patients, no difference was observed in healing time between the two groups (77.3±7.2 days vs 80.2±4.4). Instrumentation failure and screw loosening was not observed in any patient. In both group CRP and ESR decreased accordingly with response to antibiotic therapy. Surgically treated patients had significantly lower VAS scores at 1 month (3.05±0.57 in surgery group vs 5.20±1.21 in TLSO group) and 3 months (2.31±0.54 in surgery group vs 2.85±0.55 in TLSO group) post-diagnosis. Both groups had similar trends toward fast recovery in both mental (MCS) and physical components (PCS) of SF-12 questionnaire, surgically treated patients showed steeper and statistically significative improvement at 1 month (37.83±4.57 MCS in surgery group vs 24.52±3.03 MCS in TLSO group and 35.46±4.43 PCS in surgery group vs 27.07±4.45 PCS in TLSO group, p<0.001), 3 months (52.94±3.82 MCS in surgery group vs 39.45±4.92 MCS in TLSO group and 44.93±3.73 PCS in surgery group vs 35.33±6.44 PCS in TLSO group, p<0.001), and 6 months (54.93±3.56 MCS in surgery group vs 49.99±5.82 MCS in TLSO group) post-diagnosis, no statistically significant differences were detected at the other time points (9 months post-diagnosis). EQ-5D index was significantly higher in surgery patients at 1 month (0.764±0.043 in surgery group vs 0.458±0.197 in TLSO group) and 3 months (0.890±0.116 in surgery group vs 0.688±0.142 in TLSO group); no statistically significant changes were observed in segmental kyphosis between the two groups. Conclusion. Posterior percutaneous spinal instrumentation is a safe, feasible, and effective procedure in relieving pain, preventing deformity and neurological compromise. Surgical stabilization was associated with faster recovery, lower pain scores, and improved quality of life compared with TLSO conservative treatment at 1 and 3 months after diagnosis

Aim. Cefuroxime is a time-dependent antibiotic widely used as intravenous perioperative prophylaxis in spine surgery. A previous study has indicated that a single dose of cefuroxime provided insufficient spine tissue concentrations for spine procedures lasting more than 2–3 hours. Due to the fact that postoperative pyogenic spondylodiscitis is associated with prolonged antimicrobial therapy and high relapse rates, we aimed to evaluate if a twofold increase of standard dosage of 1.5g cefuroxime given as one double dose or two single doses with 4-hours intervals will lead to sufficient cefuroxime spine tissue concentrations throughout the dosing interval. Method. This is preliminary data for 8 out of 16 female pigs. Data from all 16 pigs will be included for the conference. Eight pigs were randomized into two groups: Group A received one double dose of cefuroxime (3g) as a bolus, and Group B received two single doses of cefuroxime (2×1.5g) with 4-hours intervals. Measurements were obtained from plasma, subcutaneous tissue (SCT), vertebral cancellous bone and the intervertebral disc (IVD) for 8-hours thereafter. Microdialysis was applied for sampling in solid tissues. The cefuroxime concentrations were determined using ultra-high performance liquid chromatography. Results. The time with concentrations above the minimal inhibitory concentration (T>MIC) for the clinical breakpoint MIC for Staphylococcus aureus of 4 μg/ml, was superior in all compartments when administering cefuroxime as two single doses with 4-hours intervals. For the target MIC of 4 μg/ml, the mean T>MIC in all compartments ranged between 53–73% and 85–95% for Group A and B, respectively. For both groups the area under the concentration-curve (AUC) was higher for plasma compared to the remaining compartments, and the lowest AUCs were found in the vertebral cancellous bone and the IVD. There were no differences in AUC between the two groups. Furthermore, the maximal concentrations were lower for both vertebral cancellous bone and IVD compared to both SCT and plasma. When comparing the two groups, higher maximal concentrations were found in all compartments for Group A. Tissue penetration was incomplete and delayed for all compartments and comparable between the two groups. Conclusions. Despite comparable pharmacokinetic results between the two groups, Group B exhibited superior T>MIC in all compartments for the clinical breakpoint MIC for Staphylococcus aureus of 4 μg/ml. As such administration of cefuroxime as two single doses with 4-hours intervals provided sufficient cefuroxime spine tissue concentrations for a minimum of 85% of an 8-hour dosing interval, which may be acceptable for most spine procedures

Aim. Pyogenic spondylodiscitis is associated with prolonged antimicrobial therapy and high relapse rates. Nevertheless, tissue pharmacokinetic studies of relevant antimicrobials in both prophylactic and therapeutic situations are still sparse. Previous approaches based on bone biopsy and discectomy exhibit important methodological limitations. The objective of this study was therefore to assess the concentration of cefuroxime in intervertebral disc (IVD), vertebral body cancellous bone, subcutaneous adipose tissue (SCT) and plasma pharmacokinetics after single dose administration by use of microdialysis (MD) in a large animal model. Method. Ten female pigs were assigned to receive 1,500 mg of cefuroxime intravenously over 15 min. Measurements of cefuroxime were obtained from plasma, SCT, the vertebral cancellous bone and the IVD for 8 hours thereafter. MD was applied for sampling in solid tissues. The cefuroxime concentration in both the MD and plasma samples was determined using ultra-high performance liquid chromatography. Results. For both the IVD and the vertebral cancellous bone, the area under the concentration-curve from zero to the last measured value was significantly lower than that of free plasma. Tissue penetration of cefuroxime was incomplete for the IVD, whereas for vertebral cancellous bone and SCT it was not. Furthermore, the penetration of cefuroxime from plasma to IVD was delayed. Additionally, a noticeable prolonged elimination rate of cefuroxime in the IVD was found. The maximal concentration and the elimination of cefuroxime were reduced in IVD compared to both SCT and vertebral cancellous bone. Due to this delay in elimination of cefuroxime, the time with concentrations above the minimal inhibitory concentration (T>MIC) was significantly higher in IVD than in SCT, vertebral cancellous bone and free plasma for MICs up to 6 μg/ml. Conclusions. MD was successfully applied for serial assessment of the concentration of cefuroxime in the IVD and the vertebral cancellous bone. Penetration of cefuroxime from plasma to IVD was found to be incomplete and delayed, but due to a prolonged elimination, the best results regarding T>MIC was found in IVD

Pyogenic spondylodiscitis is an uncommon but clinically relevant infection that represents 3 to 5% of all cases or osteomyelitis. In Europe, it has an estimated incidence of 0.4 to 2.4/100.000 people/year. Mortality is less than 5%, increasing with a delay in diagnosis greater than 2 month. Patients with renal failure have greater predisposition to infections, consequence of the chronic uremic state. Infection rates in Polytetrafluoroethylene (PTFE) hemodialysis grafts in end-stage renal disease (ESRD) range from 3 to 35%. We present a rare case of concurrent spondylodiscitis and PTFE graft infection in a patient with ESRD and recurrent urinary tract infections (RUTI). The authors present a case of an 80-year-old man with past medical history significant for abdominal aortic aneurysm, bilateral ureter-hydronephrosis, Pseudomonas aeruginosa RUTI and ESRD. Three months after a dialysis PTFE graft hemoaccess was performed a Pseudomonas graft infection was diagnosed and the PTFE graft was removed. One week later, the patient was observed in the author's Department due to an insidious dorsal-lumbar mechanic back pain without neurologic deficits, with progressive deterioration over the past 6 months. A T12-L1 and L1-L2 spondylodiscitis with dural compression was diagnosed and vertebral instability was documented on MRI and TC, demanding surgical treatment. Instrumented fusion with a screw and rod construct was performed from T9 to L5, along with somatic L1 and L2 debridement, and T12-L1 interbody fusion with autograft. Microbiology results were positive for Pseudomonas aeruginosa. Antibotic therapy with ceftazidime (6 weeks) and ciprofloxacin (12 weeks) was performed. Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values. No complications were documented. Four months post-surgery, the patient was asymptomatic (Visual Analogue Scale=0), with no significant limitation in his daily life activity (Disability Rating Index=85) and the vertebral body height was sustained, with imagiological signs of spinal fusion. ESRD patients are more susceptive to infections. Failure in early diagnosis and treatment may lead to disease progression and subsequent functional limitations, deformity and increase in mortality. An aggressive approach, despite delay on diagnosis, is the key factor for a worthy outcome. Despite the good results, recrudescence of spondylodiscitis is known to occur even years after the original offense is treated

The goal of this work is to evaluate the epidemiology and treatment employed in the treatment of pyogenic spondylodiscitis. Diagnosis was based on clinical and imaging, it does not include cases of postoperative infection and lesions contiguous with decubitus ulcers. The clinical records were used to obtain demography, comorbidities, presenting symptoms, physical examination, laboratorial values, diagnostic procedures, microbiological profile as well as medical and surgical treatment. Statistical analysis was performed using SPSS 20. After reviewing 22 patients met the inclusion criteria. The mean age was 60.82(range 22–86), 82 % were men(n=18). Most prevalent comorbidities were diabetes mellitus 41%(n=9), chronic alcoholism 18% (n=4), CKD 14%(n=3) and HIV in 9%(n=2). Approximately 40.1% had a septic focus in another location, the most common UTI 30%(n=3) and 20% sepsis(n=2). The most common symptoms were LBP 51%(n=21), weight loss 15%(n=6) and fever 12%(n=5). Laboratory evaluation revealed an average leukocytosis 11.8(range 4.3–21.8), ESR averaged 83.9 mm/h (range 10–128), mean CRP 11.6 mg/dl(range 0.4–38.7). The lumbar spine was the most affected segment 55%(n=12), then the dorsal 36%(n=8) and cervical 9%(n=2). The microbiological diagnosis was established in 55% of cases (n=12), 8(66.7%) cases were identified in blood cultures and 3(25%) in bone biopsy. The most common agents identified were MSSA in 18% of cases (n=4) and cogulase negative staphylococci 18%(n=4). A surgical procedure was performed in 86.4% (n=19), 7 for fusion and in 4 a transpedicular biopsy. The indications for surgery were crop material, abscess drainage and instability each with 32%(n=6). In terms of neurological sequelae 23%(n=5) had changes. The average length of stay was 57.4 days(range 19–190), mortality was 9%(n=2). We found no statistically significant differences regarding the identification of microorganisms using age (p=0.644), ESR(p=0.233), CRP(p=0.166) and leukocytosis(p=0.147) as variables. Our series has characteristics common to literature, predominantly male, risk factors as Diabetes, CKD and HIV are common. Alcoholism is linked with some immunosuppression and appears as a new risk factor. Obtaining microbiological diagnosis is crucial to avoid the need for prolonged antibiotic therapy and the potential increased costs and toxicity of broad spectrum. The low number of positive biopsy (25%) is explained by the early empirical antibiotic therapy before sampling. Surgery plays an important role in crop products for microbiological analysis and treatment of instability or neurological deficits. A high index of suspicion in patients with known risk factors and back pain is crucial since delay in diagnosis leads to worse outcomes

Purpose: To describe the percutaneous transpedicular biopsy technique as a novel way of approaching lesion of the thoracic and lumbar spine, to determine the amount of bone retrievable through the pedicle and its diagnostic yield. Material and Methods: Seventy-nine patients underwent 84 biopsies. Seventy-seven procedures were performed with ßuoroscopic guidance arid seven with CT guidance. Seventy-one biopsies underwent under local anesthesia and ten under general anesthesia. Age range of patient was from 3 to 81 years. Results: Adequate specimens for correct diagnosis were obtained in 80 of the 84 patients with the following diagnoses. Pyogenic spondylodiscitis 31, tuberculosis 4, coccidiomycosis 2, echinococcus cyst 1, blastomycosis 1, brucella 4, primary neoplasm 7, metastatic neoplasms 16, osteoporotic fractures 8, osseous repair for insufþciency fractures 5, Pagetñs disease 1. The 4 negative biopsies subsequently proven to be Ç false negative È and were related to faulty biopsy techniques. Conclusion: Pitfalls can be avoided when adhering to the details of our technique. These pitfalls can occur while retrieving the instrumentation without simultaneous withdrawal of the guiding pin; crushing pathological soft tissue against sclerotic or normal bone; or when encountering a sclerotic lesion distal to normal bone without using a sequential type of biopsy specimen-retrieval technique. Any type of bleeding is controllable. The approach is a safe, efþcacious and cost effective and avoids so the problems such low diagnostic yield nerve root injury, pneumothorax and hematoma encountered with conventional needle technique