To evaluate risk factors and outcomes of spondylodiscitis in hemodialysis patients. Retrospective case control study of twenty-two spondylodiscitis patients and forty-four control subjects. The incidence of spondylodiscitis was 8.3 cases per 1000 patient-years. Spondylodiscitis patients had been receiving hemodialysis for a significantly longer average duration (median, thirty-seven months) than control subjects (median, thirteen months; P < 0.0008). A greater proportion of spondylodiscitis patients (eighteen [82%] patients) than control subjects (six [14%] subjects; P < 0.0001) had microorganism growth from at least one blood culture within three months before diagnosis of spondylodiscitis. During the months before spondylodiscitis diagnosis, a significantly greater proportion of spondylodiscitis patients than control subjects had received blood products, had an invasive procedure, had any type of vascular access established, or had temporary or permanent internal jugular or temporary femoral central venous catheters placed. All patients with spondylodiscitis received antimicrobial therapy (mean duration, twenty-one ± fourteen weeks). The death rate was significantly greater for spondylodiscitis patients (thirteen [59%] patients) than control subjects (twelve [28%] subjects; P < 0.03; odds ratio, 2.69; 95% confidence interval, 1.03 to 7.04). Risk factors for spondylodiscitis in hemodialysis patients include antecedent bacteremia, receipt of blood products, invasive procedures, or establishment of vascular access. Spondylodiscitis in hemodialysis patients has a poor prognosis and high risk of mortality

Spondylodiscitis is a severe infectious disease of the vertebral column and the intervertebral disc space and may be complicated by an epidural abscess. A wide range of pathogens have been described as causative agents. Since several weeks of antibiotics are necessary for successful therapy detection of the causative pathogen is essential. Specific antibiotic therapy improves outcome and reduces antibiotic related complications. Antibiotic Stewardship (ABS) programs are bundled approaches aimed at improving antibiotic therapy. In 2012 an ABS program including weekly interdisciplinary clinical rounds and development of algorithms for diagnosis and therapy of patients with spondylodiscitis was established in the Department of Orthopedic Surgery in a University hospital. We evaluated the effects of ABS with regard to the appropriateness of specimen and pathogen detection and antibiotic therapy in patients with spondylodiscitis. We retrospectively analysed diagnostic procedures and pathogen detection of 100 patients that were hospitalized with spondylodiscitis and compared the data of patients that were treated before (2004–2011) and after introduction of ABS measures (2012–2014). After introduction the effect of ABS on antibiotic therapy was analysed. 100 patients with radiologically confirmed spondylodiscits were enrolled. The pre-ABS group (2004–2011) contained 58 patients. Of these no samples were taken for microbiological examination from 21 patients (36%) and from 8 patients (14%) only swabs were submitted for culture. Aspirates or tissue samples were taken from 22 patients (38%) and blood cultures from 18 patients (31%). Pathogen detection was successful in 18 patients (31%). After introduction of ABS in the beginning of 2012 aspirates or tissue samples were taken from 34 patients (81%) and blood cultures were taken from 34 patients (81%). Pathogen detection was successful in 26 patients (62%). The most commonly detected pathogens were Gram positive cocci (S.aureus, S. epidermidis, and streptococci) in 31 patients. Less common pathogens were found in 12 patients (Gram negative rods (8), fungi (3), Moraxella (1) and Propionibacterium (1). After introduction of ABS antibiotic therapy was changed in 18 of 20 patients (90%) after pathogen identification. In 50 % of cases the inappropriate empiric therapy was changed (MRSA, MRSE and Gram negative rods) and in 50 % broad-spectrum antibiotic therapy could be deescalated. ABS significantly improved the number and quality of samples, increased the number of blood cultures taken and doubled the pathogen detection rates in patients with spondylodiscitis leading to an improvement in antibiotic therapy in almost all patients with pathogen detection

Spondylodiscitis rarely coexists with endocarditis (around 5% of patients with endocarditis). Furthermore, viridans streptococci are not common pathogens of spondylodiscitis and finally the combination of spondylodiscitis and right – sided endocarditis due to viridans streptococci is rare. We present a case of right-sided native valve endocarditis due to Streptococcus mutans presenting as cervical and lumbar spondylodiscitis in a patient with obstructive cardiomyopathy. A 52 year – old man with a history of hypertrophic obstructive cardiomyopathy was admitted with fever and back pain of ten days duration, followed by torticollis. He had undergone dental therapy some weeks before symptom appearance, due to bad oral hygiene, without receiving any chemoprophylaxis. Magnetic resonance imaging revealed L4-L5 and C4-C5 spondylodiscitides. Four blood cultures drawn were all positive for Streptococcus mutans, while fine needle aspiration of the lumbar lesion was unsuccessful. Transesophageal echocardiogram revealed tricuspid and possible pulmonary valve vegetations. The patient was treated with ceftriaxone plus gentamicin for 2 weeks and then ceftriaxone only, for a total of 3 months. He had an uneventful recovery and was referred for cardiosurgical consultation. Physicians managing cases of spondylodiscitides should bear in mind to rule out endocarditis, especially in cases with underlying cardiopathy. The possibility of coexistence is even greater when there is sustained bacteremia and the pathogen isolated from blood cultures is a common pathogen for endocarditis

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.

This study examines the case of a spondylodiscitis in the thoracic spine caused by MRSA which led to two orthopaedic surgeries followed by rehabilitation.

A 72.6 year old woman suffered a cutaneous infection with herpes zoster on the right dorsal thorax – 2 weeks later she presented a sepsis by MSSA. 2 month later she lamented sever pain in the thoracic column. She were hospitalized presenting a sepsis by MRSA. One month later it was found an infectious spondylodiscitis from thoracic vertebra T 8 to T 11 with destruction of the intervertebral spaces. To eliminate the infection and stabilize the dorsal column she was undertaken an first orthopaedic surgery by dorsal decompression and dorsal spondylodesis from T 6 – L 2; intraoperative microbiology: MRSA. 3 month later she was undertaken a second surgery by a lateral transthoracic decompression and intervertebral stabilization from T 9 – T 10 with tricortical bone chips and inlay of sponge with Calcibon and Gentamycin. The following rehabilitation took her to a reasonable result. The cost of the first treatment with dorsal stabilization was € 17.694,24, the second surgery was € 13.678,88; the cost of both rehabilitations was € 4.160,00. The finally costs for the whole treatment for the insurance was € 47,442,62.

This retrospective case report shows the high costs for a treatment of spondylodiscitis caused by MRSA, not taking in consideration the harm and prolonged pain of the patient.

Aims

Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.

Introduction: MRSA spondylodiscitis is an increasingly common phenomenon. Despite this there is very little reported on it.

Objectives: Our objective was to present relevant demographics, clinical presentations and outcomes for this condition from our institution.

Methods: We performed a retrospective review of patients presenting over a six year period from 2000 to 2005.

Results: 13 cases were identified. The mean age was 65 years (range 36–92), 85% were male. All cases presented with back pain, spinal tenderness and systemic upset. Neurological deficit was present initially in 38% and a further 8% developed neurological deterioration during treatment. The thoracic spine (53%) was most commonly affected followed by the lumbar (33%), thoracolumbar junction (7%) and cervical spine (7%); 16% of cases were multilevel. The WCC, ESR and CRP were elevated in all cases with means of 17.3 ×10-9/L, 102 mm/hr and 236 mg/L respectively. In cases cured of infection, the WCC, ESR and CRP normalised at a mean of 10 weeks, 14 weeks and 19 weeks respectively. Radiological diagnosis was established with MRI in all cases. The most common risk factors were diabetes mellitus (62%), mal-nourishment (54%), cirrhosis (31%), end stage renal failure (15%) and intravenous drug use (15%). Multiple risk factors were present in 76% of cases and 15% had no identifiable risk factors. The main sources of sepsis were intravenous catheters (23%), urinary tract (15%) and intravenous drug use (15%). In cases cured of infection treatment consisted of intravenous vancomycin mono-therapy for a mean period of four weeks followed by oral combination or monotherapy antimicrobials for a mean period of 8 weeks. Operative intervention was required in 38% of cases. At six months 54% of cases were clinically free of infection, 38% had died and 8% required ongoing treatment. Neurological deficit was present in 50% of survivors. At one year 29% of survivors suffered from MRSA bacteraemia and spondylodiscitis recurrence.

Conclusion: This is a devastating condition. Clinical suspicion should remain high and prompt diagnosis and treatment is essential.

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.

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.

We report the clinical features and treatment on a rare case of Candida albicans lumbar spondylodiscitis in a non-immunocompromised patient. Its indolent course leads to delayed suspicion and diagnosis. As soon as fungal infection is suspected investigations with MRI and biopsy should be performed followed by medical therapy.

Retrospective data analysis.

A 58-year-old male underwent surgery for adenocarcinoma of the ampula of Vater treatment. Subsequently, the patient had a prolonged intensive care unit stay due to major complications, during his stay he developed a septicemia with Candida albicans isolated in the blood work. He received antifungal therapy anidulofungin, later changed to fluconazole during 2 weeks. Repeated blood work were negative and no vegetations on echocardiogram were seen. He was discharged from the ICU to a surgery floor.

During the surgical unit stay he presented with lower back pain radiating to the lower limbs. Findings on neurological examination were normal, radiographs of the lumbar spine revealed L5-S1 antero listhesis. He was treated with oral non-steroidal anti-inflammatory drugs and an lumbar MRI and orthopaedic consultation was agended. One month later, after minor trauma he developed myelopathic symptoms with weakness of both lower limbs and severe back pain. Plain radiograph showed anterolistesis worsening. Magnetic resonance imaging showed endplate erosion at L5/S1. There also was evidence of paraspinal collection with epidural compression of the dural sac.

The patient was treated surgicaly with debridement and posterior instrumented fusion from L4 to S1. Disk and end-plate material collected confirmed Candidal infection. The patient recovered most of his neurological deficit immediately after surgery. He was subsequently treated during 2 weeks with liposomal amphotericin B, later changed to fluconazole 400mg per os per day. He maintained antifungal therapy during 15 months. He remains asymptomatic with no recurrence of infection clinically or radiologically after surgery.

Fungal spondylodiscitis is rare. Sub-acute or chronic low back pain in either immunocompromised or non-immunocompromised patients cronically ill and malnourished (parental nutrition) there must be high index of suspicion for fungal infections. Therefore we recommend screening for Candida osteomyelistis in these cases. Without treatment, involvement of vertebral bodies can lead to compression fractures, deformity of the spine and neurological impairment.

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.

Introduction

Because it typically afflicts older patients with poorer health and/or risk factors, spondylodiscitis can become life threatening. Lingering symptoms, which can be attributed to residual destruction as well as concurrent degenerative changes in the adjacent segments after inflammation has subsided, are frequently present after both conservative and operative therapies. Here, quality of life outcomes are presented for patients two years after operative and conservative treatment.

To report a rare case of successfully treated synchronous shoulder septic arthritis, total knee replacement infection and lumbar spondylodiscitis in a patient with rheumatoid arthritis.

Fifty-six year old woman, with a history of rheumatoid arthritis diagnosed at twenty-five year old, and total knee replacement at fifty-four. Recently treated with etanercept, presented with acute inflammatory signs of the right shoulder in addition to right knee and lumbar back pain for 6 months. After a shoulder and knee arthrocentesis the diagnosis suspicion of shoulder septic arthritis and total knee replacement infection was confirmed. Therefore it was performed shoulder arthroscopic irrigation and debridement and the first of two stages knee revision, with implantation of antibiotic cement on cement articulating spacer. It was also diagnosed a L1–L2 and L4–L5 spondylodiscitis with dural compression documented on MRI, which determined surgical treatment. By a posterior approach it was performed instrumentation from T11 to L5, followed by L1–L2 and L4–L5 discectomy and interbody fusion with autograft. Shoulder and knee synovial fluid cultures where positive for Methicillin Sensible Staphylococcus aureus narrowing the broad-spectrum combination therapy to levofloxacin for six weeks, with symptomatic relieve and C-reactive protein and white blood cell count returning to normal values.

Almost one year down the line the patient remained with no sign of infection, even under the influence of immunosuppressive therapeutic. She returned to her previous status concerning the rheumatologic disease and the second stage knee revision is being planned to happen on the short run.

Rheumatoid arthritis patients are a high-risk group for septic arthritis considering, among others, the immunosuppressive therapeutics and the frequent history of arthroplasty. The presented case illustrates three different type of septic complication in the same patient. The timely and aggressive approach was the key factor for a good outcome.

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.

Introduction and Objectives: Given the increase in incidence of some pathological conditions in the musculoskeletal system, we proposed carrying out an observational study on the clinical and epidemiological characteristics of infectious spondylodiscitis (IS) diagnosed in our sanitary area over the last 8 years.

Materials and Methods: We performed a retrospective analysis of the clinical histories of patients with tuberculosis infectious spondylodiscitis and spondylodiscitis due to other causes diagnosed between January 2000 and December 2008. We included those cases in which a compatible clinical and radiological picture associated with isolation of the microorganism in hemoculture or in material taken from the focus of the spondyle. We also considered there was a proven diagnosis of spondylodiscitis if there were typical caseified granulomas in vertebral biopsies or concomitant extravertebral foci.

Results: We found 14 spondylodiscites due to other causes and 5 spondylodiscites due to tuberculosis. All spondylodiscites due to other causes were caused by monobacterial infections except one, and the most frequent microorganism found was Staphylococcus aureus (5) followed by S. epidermidis (3) and E. coli (3). The spondylodiscites due to tuberculosis required more interventions to decompress and/or drain paravertebral abscesses and had more neurological sequelae.

Discussion and Conclusions: Infectious spondylodiscitis is more frequent and predominates in the low dorsal and lumbar spine segments. During the last decade there has been a notable increase in spondylodiscitis due to other causes, with a significant amount in relation to invasive procedures. Infectious spondylodiscitis takes longer to diagnose and are associated with a greater prevalence of sequelae. Some of the possible complications are paravertebral abscesses and vertebral compression.

Summary. Between January 2003 and October 2004,12 patients with non tuberculous spondylodiscitis were treated by radical debridment, reconstruction and stabilization. In our group 9 patients underwent posterior procedure and 3 underwent combined anterior and posterior procedures. 3 of these had fungal and 9 pyogenic infections. All the patients had appropriate antimicrobial therapy All patients had excellent to good functional results and no evidence of infection at 2 year follow-up.

Introduction. Surgical treatment of nontuberculous spon-dylodiscitis of lumbar spine is challenging due to extensive bone involvement and comorbid conditions. This study is to assess the role of radical debridment followed by reconstruction and stabilization of affected segments in reducing morbidity and mortality in these patients.

Methods. 12 consecutive patients were operated between January 2003 and October 2004. Patients presented with severe back pain, root compression or paraparesis.7 cases had prior spinal surgery. Blood and radiological investigations were diagnostic. All these patients underwent radical debridement, reconstruction and stabilization of affected segments done with titanium pedicular screws, titanium mesh cages, cancellous iliac crest graft. Only posterior procedure in 9 cases, combined anterior posterior in 3 cases followed by adequate and appropriate antimicrobials therapy. Follow-up ranged from 25 to 35 months.

Results: 3 cases were fungal and 9 were pyogenic infection. Oswestry low back questionnaire, kirkaldy-willis criteria showed dramatic improvement of function. All the blood parameters were normalized in 3 months.1 case had dural tear which was repaired immediately,3 cases had wound exploration and lavage. No major complications were encountered. All cases showed Radiological fusion at last follow-up.

Discussion: Radical debridement of necrotic material, decompression of neurological structures, create a good vascularised environment. Restoring stability compromised by either infection or prior surgery helps in healing process and reduces morbidity of patients

Significance: Reconstruction using pedicular system and interbody devices can safely be used in presence of non tuberculous infection provided debridement has been radical.

In the recent years the number of patients treated for infective spondylodiscitis at our institution increases steadily. In a previous analysis it was demonstrated that Staphylococcus aureus was the most frequent pathogen causing this infection. The aim of the present study was to evaluate whether infection with this pathogen carries also a worse prognosis.

Case records of patients treated for spondylodiscitis at the Department of Infectious Diseases, Ljubljana in the years 1990 – 2006 were reviewed. The following data were recorded: age, sex, clinical features, causative agents, underlying disease, previous or concomitant infections, previous operations, results of x-ray and other diagnostic examinations, complications and outcome of the disease. The data were analysed using EpiInfo 6.

One hundred twenty six patients (78 males, 48 females) with infective spondylodiscitis were analysed in this study. The mean age was 61.6 years (range: 20 – 95 years). In 97 (77%) patients the causative pathogen was demonstrated. S. aureus was the most frequent pathogen isolated in 66 (52.4%) out of all the patients and in 65% of all microbiologically documented infections. Only two isolates were methicillin-resistant. Staphylococcal infection was significantly more frequent in male than in female patients (P = 0.04). There were no significant differences in age, underlying diseases, previous operations and other risk factors between patients with staphylococcal and non-staphylococcal spondylodiscitis, although patients with non-staphylococcal infections were more likely to have a previous infection during the six months before the beginning of their illness. Case-fatality rate was 9.5%, 12 patients died. There was no difference in mortality between the two groups, but patients with staphylococcal infections had significantly more complications such as epidural or paravertebral abscesses (P < 0.002) and were also more frequently operated on (P = 0.02). The duration of treatment and hospitalisation did not differ significantly between those two groups. In 9/128 (7.3%) patients, infective endocarditis was also found.

S. aureus remains an important pathogen causing spondylodiscitis. Mortality in recent years has decreased significantly at our institution but our results show that patients with staphylococcal spondylodiscitis tend to have a more severe course of the disease and are more often in need of surgical intervention.

Aim: Presentation of the application of the transcervical system of posterior spinal fusion Varigrip in spinal infections showing its rapid and safe application and also its stability to the spinal level where it is applied to.

Patients and Methods: 22 patients (13 men / 9 women) with mean age 50, 6 years (18–79) and mean follow up time is 34,6 months (9–62) were included in our study. In 10 patients the level was in lumbar spine and in 12 in thoracic spine. In their admission 16 patients had neurological deficit and 22 mean pain score according to VAS 8, 4 (6–10). ESR was increased in 14 patients, CRP in 20 and 7 patients had also increased WBC. All 22 patients had increased signal of Tc” and 69Ga in the level of the lesion and also pathological signal in MRI (Tl, T2 and Tl with Gadolinium). All the patients underwent posterior spinal fusion using Varigrip system and 17 of these underwent in the same time somatectomy and anterior fusion.

Results: Pathologic organism was isolated to all the patients. In 20 patients the tissue culture of the lesion isolated the pathologic organism and the other 2 patients came to us with positive blood cultures from other hospitals. 6 months postoperatively 21 patients referred pain score according to VAS 2,4 (1–4) and 1 patient had no improvement (5–7). 1 patient died of PE, another of chest infection and one of head injury. 1 patient had recurrence of the infection in another level, 1 had herpeszoster and 1 had infection of the surgical wound. All the patients had neurological improvement postoperatively.

Conclusions: The method is characterized as safe because of avoidance of the neurological structures. It can be applied also safely to patients with osteoporosis. Its application is rapid so the surgical time is minimum and also it doesn’t need image intensifier during the surgical procedure. It can be applied easily either in thoracic or lumbar spine and it provides stability of the spine.

Aims: The aim of the study was to evaluate the clinical characteristics of patients with infective spondylodiscitis and concomitant endocarditis.

Methods: In the present study clinical features of patients with infective spondylodiscitis and endocarditis were compared to those without endocarditis. Case records of patients with infective spondylodiscitis treated at the Department of Infectious Diseases in Ljubljana in years 1991 to 2007 were reviewed. The following data were recorded: age, sex, underlying disease, previous or concomitant infections, previous operations, clinical features, causative agents, results of x-ray and other diagnostic examinations, complications and outcome of the disease. The Duke criteria were used for the diagnosis of endocarditis. The data were analysed using Epi Info 6 statistical programme. Patients with endocarditis were compared with others using Chi square, t-test and Mann-Whitney test.

Results: During the study period 149 patients with infective spondylodiscitis were diagnosed. There were 92 (61.7%) males and 57 (38.3%) females, aged 13 to 95 years, mean 61.0 ± 14 years. Eleven (7.0%) out of 149 patients with infective spondylodiscitis had concomitant endocarditis, two of them on prosthetic valves. The causative pathogen in patients with endocarditis was Staphylococcus aureus in seven (MRSA in two), mixed infection, Streptococcus viridans, Pseudomonas aeruginosa and coagulase negative staphylococci in one each. Staphylococcus aureus was the most common causative agent of infective spondylodiscitis. Among the three patients with MRSA spondylodiscitis, endocarditis was also present in two. Patients with concomitant endocarditis were similar to those without it but the two groups differed in mortality which was significantly higher in the group of patients with endocarditis (36% vs. 10%.; p < 0.05). In three patients (who died) spondylodiscitis presented at the same time as acute endocarditis and the clinical picture was predominantly that of severe endocarditis. In five patients (one of whom died) spondylodiscitis manifested late in the course of endocarditis and in one patient spondylodiscitis preceded endocarditis. In two patients endocarditis was diagnosed on routine echocardiography performed for staphylococcal sepsis. The urgent valve replacement was performed in two patients but was followed with relapse of endocarditis in one of them.

Conclusions: Although rarely, association of infective spondylodiscitis with endocarditis conveys a poor prognosis especially in the setting of acute staphylococcal endocarditis.

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.