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.

The principle of open reduction and internal fixation developed during the last few decades provides satisfactory alignment and articular function. The disadvantages of this technique are a large area of surgical exposure with risk of bone avascular necrosis, non-union, infection and stiffness. With LISS (Less Invasive Stabilisation System) the percentage of these problems can be reduced.

Over the period January 2003–March 2004, at the Orthopaedics and Traumatology Operative Unit of Maggiore Hospital in Bologna, Italy, 15 patients with distal femur fractures were treated by the use of LISS. Two of them were excluded at the time of follow-up: they died 2 and 12 months after the operation. Thus, we studied outcome in the remaining 13 patients. The average age was 49.7 years (range 18 to 88). According to the AO classification system we had four type 33.A1 fractures, six type 33.A3 fractures, two type 33.C2 fractures, one type 33.C3 fracture and one type 32.A3 open fracture. The mean follow-up was 9.8 months (range 3 to 17 months). Clinical and radiographic assessment was performed using the Neer-Grantham-Shelton score. The mean final score was 70.9/100. The average time of bony union was 12 weeks. We had three complications. In one patient there was a proximal pull out a few days after surgery; however, a satisfactory bony union was obtained with a second operation by a new LISS and a bone graft performed 1 month after the first operation. In the other two patients we had to remove the LISS because of pain at 2 and 14 months after surgery. These complications can be easily explained by the lack of experience in applying this kind of implant and the peculiarity of the cases.

We conclude that LISS is an effective system for healing distal femur fractures, with no direct surgical exposure of the fracture site, little bleeding, and early mobilisation and union.

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.