Introduction: Purpose of this study is to evaluate retrospectively 61 cases of spinal infections, unrelated to previous spinal surgical treatment. We included patients with drug addiction. Objective of this study is to analyze the results of treatment using a diagnostic and therapeutic algorithm. This procedure may allow a systematic and comprehensive approach to the diagnosis and management of vertebral osteomyelitis. For instance, despite advances in imaging, this pathology is easily missed and treatment is often delayed.

Materials and Methods: We reviewed 61 patients aged 15–83 (average 52y) treated between January 1997 and March 2001. All patients received plain radiographs, gadolinium enhanced magnetic resonance imaging, Ga-67 and Tc-99 scintigraphy. A total of 36 patients underwent CT- guided fine-needle aspiration biopsy: the coltures of spinal specimen were positive in 47% (17/36) of cases. Blood coltures were positive in 65% (13/20).

Results: Staphylococcus Aureus was the main organism followed by Mycobacterium Tubercolosis and Staphylococcus Epidermidis. All patients received intravenous antibiotics. Neurologic impairment was present in 13 (26%) patients who underwent surgery. All patients with paresis recovered completely after surgical decompression (100%). Patients with nonsurgical spondylodiscitis were treated with bed rest and bracing. They reported residual back pain not frequently 22% (8/36) than patients treated surgically 38% (5/13).

Conclusions: the outcome of patients with vertebral osteomyelitis in general is favourable when appropriate treatment is picked even if vertebral osteomyelitis is a rare condition and because of this often overlooked initially. Delay in diagnosis may results in spine impairment, more hospitalisation time and more cost. We suggest diagnostic and therapeutic criteria in order to simplify the treatment.

Haematogenous vertebral osteomyelitis (HVO) is a relatively rare disorder which accounts for 2–4% of all cases of infectious bone disease. In recent years, the incidence of spinal infections seems to have increased according to the growing number of intravenous drug users in young people and with the use of intravenous access devices, genitourinary surgery and manipulation in the elderly. Men are more frequently affected than women, with an average age of onset in the fifth and sixth decade of life. The onset of symptoms is typically insidious, with neck or back pain often underestimated by the patient. The early diagnosis is also difficult due to the non-specific nature of laboratory and radiographic findings. The frequent observation of back pain also makes the diagnosis a challenge in most cases. Several studies in the literature report an average delay in the diagnosis of HVO from 2 to 6 months after the beginning of the symptoms. In this article we review the clinical features and the diagnostic approach to HVO in order to optimise treatment strategies and follow-up assessment.

From 1997 to 2003 we treated 153 patients affected by vertebral osteomyelitis. The localisation was cervical in 11.5% of the cases, thoracic in 31% and lumbar in 57.5% cases. In all, 92 CT needle biopsies were performed without any complications. We were able to identify the microbiological pattern in 57% of cases (the most represented bacteria were Staphylococcus aureus and Mycobaterium tuberculosis) whereas in 47% of cases we could not identify any micro-organismus. Treatment was conservative in 112 cases and surgical in 41 cases.

Most of the studies in the literature consider HVO as a challenge for the physician: symptoms are not specific and sub-acute or chronic presentation is most common. In general, a delay in diagnosis is the rule rather than the exception. This is an easily missed infectious process, particularly in the elderly, in whom degenerative radiographic changes and conditions resulting in back pain, such as osteoporotic fractures or spinal metastases, are common and signs of sepsis may not become manifest. However, persisting localised back pain and tenderness with elevated ESR should prompt the physician to also consider HVO, although fever and leucocytosis may often not be present.

Once HVO is suspected, a long series of imaging and laboratory tests, and if necessary surgical procedures, must be initiated. The purpose of this study is to formulate a systematic, comprehensive and simple approach to the management of this disease following the diagnostic algorithm suggested.

Aims: Evalutation of the different surgical option (simple decompression and stabilization vs. intralesional excision vs. en bloc resection) in the treatment of spinal metastases from RCC. Methods: Sixty-one cases in 56 patients with symptomatic spine metastases secondary to Renal Cell Carcinoma (RCC) were treated between 1991 and august 2002. The metastases was located in 43 cases in the lumbar spine, in 23 cases in the thoracic spine and in 4 cases in the cervical spine. Twelve patients were submitted only to radiation therapy. Different procedure was done in the remainder cases: in 16 cases a palliative procedure, in 22 cases a curettage and in 6 cases a en bloc resection. Radiation therapy (RTR) was performed after surgery in 37 cases, Selective Arterial Embolization (SAE) in 29 cases, Chemotherapy (different protocols) in 5 cases and Immunotherapy (IL 2+IFN) in 22 cases. Results: Fifteen patients only were followed for 24 months at least. Of 3 patients submitted to palliative surgery, 1 is alive without disease (NED) at 28 months from treatment, while 2 are dead at 24 and 27 months. Of 10 patients submitted to curettage 5 are continuous disease free (CDF) (24 to 44 months; average: months); 1 is NED at 56 months, 2 are alive with disease (AWD) at 24 and 25 months and 2 are dead after 40 and 68 months. Two patients were submitted to en bloc resection and are CDF at 24 and 30 months after tretament. Conclusions: The treatment of spine metastases of RCC is multidisciplinary: the eligibility of patients to en bloc resection both on the basis of general conditions and local tumor expansion is critical for the local control of the disease. If en bloc resection is not feasible, combination of SAE, complete intralesional excision, RTR, Immunotherapy seem to be the most appropriate treatment.

Aims: To demonstrate the possibility to apply in the spine the same principles of surgical oncology adopted for primary bone tumors of the limbs. Methods: From 1-1-1992 to the end of 2001 seventy-seven primary malignant and aggressive benign bone tumors and 27 solitary metastases were treated. The primary tumors were classiþed according to Enneking oncological system and Weinstein-Boriani-Biagini surgical system. The en bloc resection were performed in 3 cervical, 34 thoracic, in 28 lumbar, in 29 thoracolumbar, and 10 in lumbosacral lesion. Reconstruction was performed, aiming to replace the resected elements of stability. Results: In 71 patients a wide margins was achieved, in 19 a marginal margin, in 14 an intralesional margin. No patients died during surgery or from surgical complications. Twenty-six patients were died for at least 1 month (1 to 71 months; average 29) All the other cases (78 patients) were followed for at least 12 months (12 to 366 months, average: 55 months). At þnal follow-up, sixty-seven (64,4%) patients were found continuous disease free ( CDF, 12 to max 366 months; average: 65 months), 6 (5.7%) with no evidence of disease ( NED 13 to 186 months; average: 93 months), 5 (4,8%) alive with disease ( AWD 12 to 75 months; average: 34 months); 13 local recurrence on 104 cases (12.5%) were observed and treated (6 to 126 months; average: 37 months). 4 cases developed bone metastases and 3 patients lung metastases. Conclusion: En bloc resection can be performed in selected tumors of the spine; the indication to such major surgery must be based on the oncologic stage, and the procedure must be carefully planned. For this purpose, the Weinstein-Boriani-Biagini system could be a helpful tool.