Aims. Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre. Methods. A retrospective review was performed of all gram-negative spinal infections (n = 32; median age 71 years; interquartile range 60 to 78), excluding surgical site infections, at a single centre between 2015 to 2020 with two- to six-year follow-up. Information regarding organism identification, antibiotic regime, and treatment outcomes (including clinical, radiological, and biochemical) were collected from clinical notes. Results. All patients had comorbidities and/or non-spinal procedures within the previous year. Most infections affected lumbar segments (20/32), with Escherichia coli the commonest organism (17/32). Causative organisms were identified by blood culture (23/32), biopsy/aspiration (7/32), or intraoperative samples (2/32). There were 56 different antibiotic regimes, with oral (PO) ciprofloxacin being the most prevalent (13/56; 17.6%). Multilevel, contiguous infections were common (8/32; 25%), usually resulting in bone destruction and collapse. Epidural collections were seen in 13/32 (40.6%). In total, five patients required surgery, three for neurological deterioration. Overall, 24 patients improved or recovered with a mean halving of CRP at 8.5 days (SD 6). At the time of review (two to six years post-diagnosis), 16 patients (50%) were deceased. Conclusion. This is the largest published cohort of gram-negative spinal infections. In older patients with comorbidities and/or previous interventions in the last year, a high level of suspicion must be given to gram-negative infection with blood cultures and biopsy essential. Early organism identification permits targeted treatment and good initial clinical outcomes; however, mortality is 50% in this cohort at a mean of 4.2 years (2 to 6) after diagnosis. Cite this article: Bone Jt Open 2024;5(5):435–443

Aims. This multicentre, retrospective study aimed to improve our knowledge of primary pyogenic spinal infections in children by analyzing a large consecutive case series. Patients and Methods. The medical records of children with such an infection, treated at four tertiary institutions between 2004 and 2014, were analyzed retrospectively. Epidemiological, clinical, paraclinical, radiological, and microbiological data were evaluated. There were 103 children, of whom 79 (76.7%) were aged between six months and four years. Results. We confirmed a significant male predominance in the incidence of primary pyogenic spinal infections in children (65%). The lumbar spine was the most commonly affected region, and 27 infections (26.2%) occurred at L4/5. The white blood cell count was normal in 61 children (59%), and the CRP level was normal in 43 (42%). Blood cultures were performed in 95 children, and were positive in eight (8%). A total of 20 children underwent culture of biopsy or aspiration material, which was positive in eight (40%). Methicillin-sensitive Staphylococcus aureus (MSSA) and Kingella (K.) kingae were the most frequently isolated pathogens. Conclusion. MSSA remains the most frequently isolated pathogen in children with primary pyogenic infection of the spine, but K. kingae should be considered as an important pathogen in children aged between six months and four years. Therefore, an empirical protocol for antibiotic treatment should be used, with consideration being made for the triphasic age distribution and specific bacteriological aetiology. In the near future, the results of polymerase chain reaction assay on throat swabs may allow the indirect identification of K. kingae spondylodiscitis in young children and thus aid early treatment. However, these preliminary results require validation by other prospective multicentre studies. Cite this article: Bone Joint J 2018;100-B:542–8

Introduction. Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections. Materials & methods. Sheffield Spinal Infection Database collects data prospectively from regularly held Spinal infection MDTs. We accrued 125 spinal infections between September 2008 and October 2010. The medical records, blood results, radiology and bacteriology results of all patients identified were reviewed. In patients with negative first biopsy, second biopsy is contemplated and parenteral broad spectrum antibiotic treatment initiated. Results. There were 81 pyogenic, 16 tuberculous and 28 postoperative spinal infections. The mean age was 58.4 years (range, 19 to 88 years). There were 71 male and 54 female patients. There were 64 lumbar and 26 thoracic infections. Two level and multi-level spinal infections involving more than two segments occurred in 30 patients. Of sixty positive microbiology yields, the most common organism was methicillin sensitive staphylococcus aureus (n-23) followed by Streptococcal, E Coli and Coagulase negative staphylococcal and Pseudomonas infections. Second biopsy (done when first biopsy negative) was only positive in two patients. Conclusions. Annual incidence of de novo spinal infection was 48 (pyogenic-40, tuberculous-8). The most frequently isolated pathogen was Staphyloccus aureus. Multi-level infection, diabetic patients, resistant TB and postop infection in elderly patients constituted the ‘difficult to treat’ group in our experience. An algorithm for the diagnostic work-up and management of spinal infections is proposed

Aim. Spondylodiscitis and vertebral osteomyelitis can lead to long-term sequelae if not diagnosed and treated promptly and appropriately. The Royal National Orthopaedic Hospital (RNOH) has devised a new spinal infection referral system within the UK that allows cases to be discussed in a specialist multi-disciplinary (MDT) forum. National guidelines were devised in 2013 to help guide treatment, which recommends both tissue biopsies from the affected region and a MRI of the entire spine. The aims of this study were to assess the current treatment and referral practices and compare them with the set guidelines. It is hypothesised that a high percentage of patients are started on antibiotics without a biopsy or a positive set of blood cultures, a low percentage of patients are referred without undergoing a MRI of the full spine and that there is a long delay in referral to the MDT. Method. A retrospective case study analysis was carried out on all spinal infection referrals received by the Royal National Orthopaedic Hospital over a 2-year period (2014–16), using the standards set by the current national guidelines. Clinical features, haematology results, imaging, biopsy results, treatment and outcome were all reviewed. Three key areas were addressed; whether antibiotics were commenced before positive cultures or biopsy, whether a MRI of the entire spine was performed and the time taken for referral from the onset of symptoms. Results. A total of 49 cases were identified, the average age was 56 years and the majority were male (67%). The most common organisms grown were staphylococcus aureus and mycobacterium tuberculosis. Lumbar (37%) and thoracic (31%) spine were the most predominant regions affected. As predicted only 42% of the patients were referred with a whole spine MRI, only 33% had a biopsy and 29% had positive blood cultures before starting antibiotics. The average time to referral was 62 days overall (10 days for acute referrals). Conclusions. This multicentre study highlights a number of key concerns with both the referral and treatment of spinal infections. New national infection guidelines recommend a tissue sample prior to antibiotics; however this study showed that only 45% of patients had either a biopsy or positive blood culture before starting antibiotics. The time to referral was prolonged and the majority of patients did not receive a whole spine MRI. Overall this confirms the study's hypothesis and the need for better management of this complex and debilitating condition

Background. There is minimal published data regarding the long-term functional outcome in pyogenic spinal infection. Previous studies have used heterogeneous, unreliable and non-validated measure instruments, or neurological outcome alone, yielding data that is difficult to interpret. We aim to assess long-term adverse outcome using standardised measures, Oswestry disability index (ODI) and MOS short form-36 (SF-36). Methods. All cases of pyogenic spinal infection presenting to a single institution managed operatively and non-operatively from 1994-2004 were retrospectively identified. Follow-up was by clinical review and standardised questionnaires. Inclusion in each case was on the basis of consistent clinical, imaging and microbiology criteria. Results. Twenty-nine cases of pyogenic spinal infection were identified. Twenty-eight percent were managed operatively and 72% with antibiotic therapy alone. Nineteen patients (66%) had an adverse outcome at a median follow-up of 61 months, despite only 5 patients (17%) having persistent neurological deficit. A significant difference in SF-36 PF (physical function) scores was observed between patients with adverse outcome and patients who recovered (p=0.003). SF-36 scores of all patients, regardless of management or outcome, failed to reach those of a normative population. A strong correlation was observed between ODI and SF-36 PF scores (rho=0.61, p<0.05). Seventeen percent (n=5) of admissions resulted in acute sepsis-related death. Subgroup analysis revealed delay in diagnosis of spinal infection (p=0.025) and neurological impairment at diagnosis (p<0.001) to be significant predictors of neurological deficit at follow-up. Previous spinal surgery was associated with adverse outcome in patients requiring readmission within 1 year of hospital discharge following first spinal infection (p=0.018). No independent predictors of adverse outcome, persistent neurological impairment, readmission within 1 year or acute death were identified by logistical regression analysis. Conclusions. High rates of adverse outcome detected using SF-36 and ODI suggest under-reporting of poor outcome when ASIA score alone is used to qualify outcome

Introduction: Haematogenous pyogenic spinal infection encompasses spondylodiskitis, septic discitis, vertebral osteomyelitis and epidural abscess. Management of pyogenic spinal infection can involve conservative methods and surgical intervention. We carried out a retrospective review of 48 cases of pyogenic vertebral osteomyelitis presenting over a twelve-year period to the National Spinal Injuries Unit of the Republic Of Ireland. Our objective was to analyze the presentation, aetiology, management and outcome of 48 cases of non-tuberculous pyogenic spinal infection. Methods: Both the Hospital Inpatient Enquiry (HIPE) System and the National Spinal Injuries Unit Database were used to identify our study cohort. The medical records, blood results, radiologic imaging and bacteriology results of all patients identified were reviewed. Results: The average age of presentation was 59 years with an almost even distribution between males and females. Most patients took between three and six weeks to present to hospital. Diagnosis was confirmed by serological testing of inflammatory markers and radiological imaging. The most frequently isolated pathogen was Staph. aureus (75% of cases). 94% of cases were managed by conservative measures alone, including antibiotic therapy and spinal bracing. However, in 6% of cases surgical intervention was required due to neurological compromise or mechanical instability. Conclusions: With this large cohort of non-tuberculous, pyogenic spinal infections from the NSIU, we conclude that Staph. aureus is the predominent pathogen. In the vast majority, conservative management with antibiotic therapy and spinal bracing is very successful. However in 6% of cases surgical intervention is warranted and referral to a specialist centre is appropriate

Introduction: Spinal infections are uncommon, but if the diagnosis is delayed or missed, serious consequences may occur. Recently, there have been major advances in diagnosis and treatment of spinal infections. Aim: To document the evolving clinical picture, diagnosis and treatment of spinal infection over 20 years. Methods: Prospective and retrospective data were collected by the infectious diseases services of a metropolitan referral centre and a provincial region. The clinical features, investigations, treatment and outcomes were analysed and comparisons were made between two periods; 1980–1992 and 1993–1999, and between the separate centres. Results: One hundred and fifteen patients presented, with an estimated incidence of 1.7 cases/100,000/yr. The median age increased from 55 to 63.5 years and median time to diagnosis decreased from 28 to 21 days. The most common symptom was local back pain [112/115 (97%)] and the most common sign was local tenderness [88/115 (77%)]. A fever was present in 73/115 [63%]. Forty-one patients had neurological signs [36%] and 50 [43%] had epidural masses. MRI scanning was the most accurate imaging method. All patients received antimicrobial therapy, 27 [23%] partly through an at-home programme. Forty-nine patients [43%] required surgery. At follow-up, 76% were considered cured without neurological deficits. The outcomes improved over time and the differences between services reflected referral patterns. Conclusions: Over the last 20 years the management of spinal infection has evolved through new diagnostic technology, prolonged treatment with antimicrobials, appropriate surgical intervention and a multidisciplinary approach. Heightened awareness of the condition is required to minimise the potentially serious consequences

The purpose of this retrospective study was to analyze the indications for spinal instrumentation, report the clinical features, operative details and outcome in 16 patients with active pyogenic spinal infection. Between January 1991 to October 1999, 81 patients with spontaneous pyogenic spinal infection were treated at the authors’ institution. Surgery (other than biopsy) was indicated in 24 patients for neurological deterioration, deformity or instability. Sixteen of these patients were treated with instrumentation in the presence of active spinal infection. Six patients underwent combined anterior and posterior procedures. 10 had a posterior procedure only. Outcomes assessed were control of infection, neurology, fusion, back pain and complications. At a mean follow up period of 26. 9 months, all surviving patients were free of clinical infection. None of the patients had neurological deterioration. All patients who had neurological deficit preoperatively improved by at least one Frankel grade. A solid fusion was achieved in 15 patients. 12/15 patients remained asymptomatic or had very little pain. The remaining 3 patients had mild to moderate back pain. The mean correction of the kyphotic deformity was 18. 92 degrees. Postoperative complications included bronchopneumonia, nonfatal pulmonary embolism and seizures in 3 patients. One patient developed progressive kyphosis despite instrumentation but eventually fused in kyphus. Given early recognition of pyogenic spinal infection, most cases can be managed non-operatively. Our results support that instrumented fusion with or without decompression may be used safely when indicated without the risk of recurrence of infection. Instrumentation facilitates nursing care and allows early mobilisation. For biomechanical reasons, a combined procedure is probably indicated for lesions above the conus. For lesions below the conus, we were able to achieve successful results with posterior approach only

Purpose. To report a retrospective study of 103 cases of primary spinal infection, the largest ever such series from the UK, analysing presenting symptoms, investigations, bacteriology and the results of treatment. Method. This is a retrospective review of all patients (54 Male, 49 Female) treated for primary spinal infection in a Teaching Hospital in the UK. Results. Patients predominantly presented with back pain (78%). Mean time from onset of symptoms to presentation was 72 days. The majority of cases involved patients over 50; however a significant peak also occurred amongst patients in their 20s and 30s. Common co-morbidities in the older age group included diabetes mellitus, renal failure and malignancy whereas the prevailing co-morbidity in the younger group was intra-venous drug abuse. White cell count was infrequently elevated in cases of spondylodiscitis but more commonly so with epidural abscess. The CRP was elevated in most cases at presentation and fell by an average of 62% by the time of discharge. Biopsies were performed in 60% of cases with open biopsy significantly more likely to yield a positive culture than percutaneous techniques. Epidural abscess was the most common diagnosis (42%) with spondylodiscitis, isolated vertebral osteomyelitis and discitis occurring less frequently. The most commonly isolated organism was staphylococcus aureus (51%). Of these, ten cases were infected with Methicillin Resistant Staphylococcus Aureus (MRSA). No organism was isolated in 37% of cases. 28 % of patients were treated with antibiotics alone; the remainder also underwent surgery, most frequently by a posterior approach. Fusion was achieved in 42%. 86% of patients improved symptomatically and 89% cases of paraparesis recovered to some degree after surgical decompression. Conclusion. Our overall impression is of the emergence of a young group of patients with primary spinal infections relating to Intravenous Drug Abuse and of increasing incidence of MRSA as a causative organism

Aim: To assess the functional outcome following spinal infection. Method: 42 patients who had been treated in our unit for primary spinal infection between 1995–2005 were identified. 33 who were still alive at the time of study, were sent postal questionnaires. Average length of follow up was 5.4 years (rang 0.6–10.5). The non-respondents were contacted by phone two weeks later. Overall 29 (88%) were traced. Results: Mobility score dropped in 10 (34%) patients whilst domestic circumstances’ score dropped only in 1 (3.4%). Oswestry disability score averaged 18% (range 0–53%). 16 (62%) had mild or no disability, 7(27%) had moderate and 3 (12%) had severe disability. Neck disability index in all those with cervical spine infection was between 10–20% indicating mild disability. Hospital anxiety and depression score for anxiety was normal for 25 (86%) and that for depression was normal for 27(93%) patients. Ten point Visual Analogue Score (VAS) for pain intensity when doing the questionnaire averaged 1.3 (range 0–9) with 19 (66%) having no pain, 9 (31%) mild to moderate (1–5 score) and 1 (3%) having severe pain (6–10 score). Mean VAS over one week was 1.8(range 0–9) with 14(48%) having no pain, 13(45%) mild to moderate and 2 (7%) having severe pain. VAS for distress averaged at 1.8 (range 0–9), 22 (76%) patients were coping very well (8–10 score) and poor coping (0–4 score) was seen in 1 (3%). Conclusion: Most patients after spinal infection return to activities of daily living with little or no pain and psychological sequelae. A proportion of patients however end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection

Aim: To report our ten year experience of primary haematogenous spinal infection. Method: Retrospective case note review of 42 patients presented to our unit with primary spinal infection between 1995–2005 was carried out. Demographic data, timing and modes of presentation, investigations, and methods of treatment were analysed. Information with regard to Mobility, Domestic circumstances, Oswestry disability index(ODI), Hospital Anxiety and depression score(HAD), Visual Analogue Score (VAS) for pain and coping were obtained. The cost benefit of Home Intravenous Antibiotics Service (HIAS) was also investigated. Results: Mean age was 59.9 years (1–85) with almost equal gender distribution (M 20: F 22). Axial pain was universal. Pyrexia was seen in 62%. Time from presentation to diagnosis averaged 19days (range 0–172). Sensitivity for MRI and plain x-ray was 100% and 46% respectively. Treatment ranged from intravenous antibiotics alone to combined anterior and posterior surgery depending on the presence or absence of significant collection, neurological deficit and structural threat. Mean duration of intravenous antibiotics was 54 days (range 13–240). At mean follow up of 5.4 years (0.6–10.5) there was no mortality directly related to the infection. Recurrence rate was 14%. Significant past medical history(P=0.001), constitutional symptoms(p=0.001) and pyrexia at presentation(0.001) were positively associated with recurrence. Mobility score dropped in 34% patients whilst domestic circumstances’ score dropped only in 34%. ODI averaged 18% (range 0–53%). Mean HAD for anxiety and depression was normal for 86% and 93% of patients respectively. VAS for pain averaged 1.3 (range 0–9) and that for distress was 1.8 (range 0–9). Overall it was calculated that HIAS had saved a total of 940 in-patient days. Conclusion: Primary spinal infection is a treatable condition. Disease and patient characteristics dictate the management strategy. Although most patients can regain their pre infection mobility and go back to their pre morbid domestic circumstances with little or no pain and psychological sequel, a proportion of patients end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection. Finally, HIAS was cost effective

There is little published data concerning long-term outcome in pyogenic spinal infection. Previous studies have used either neurological outcome in isolation, or non-validated quality of life measure instruments yielding data that is difficult to interpret. To assess long-term outcome following pyogenic spinal infection through standardised outcome measures, Oswestry Disability Index (ODI) and Short Form-36 (SF-36) were utilised. All cases of pyogenic spinal infection presenting to a single institution over the period 1993–2003 were retrospectively identified. Inclusion in each case was based on consistent clinical, imaging and microbiology criteria. The follow-up was by clinical review, American Spinal Injury Association (ASIA) classification, ODI and SF-36. The outcome was compared to normative data for the Irish population. Twenty-nine cases of pyogenic spinal infection were identified. Nineteen patients (66%) had an adverse outcome at a median follow-up of 61 months, despite only 5 patients (17%) who had persistent neurological deficit according to ASIA classification. A significant difference in SF-36 PF (physical function) scores was observed between patients with adverse outcome and those who recovered (p=0.003). SF-36 scores failed to reach those of a normative population, even after apparent full recovery. A strong correlation was observed between ODI and SF-36 Physical Function scores (rho=0.61, p< 0.05). Seventeen percent (n= 5) of admissions resulted in acute sepsis-related death. Delay in diagnosis of spinal infection (p= 0.025) and neurological impairment at diagnosis (p< 0.001) were associated with neurological deficit at follow-up examination. Previous spinal surgery was a significant predictor of adverse outcome in patients requiring readmission < 1 year (p= 0.018). The finding of high rates of adverse outcome and using SF-36 and ODI suggests under-reporting of poor outcome in other series. We advocate use of validated standardised spinal outcome questionnaires to accurately assess long-term outcome and facilitate comparison between case series

Back ground:. The aim of this study is to evaluate the long-term outcome after posterior spinal stabilization surgery for the management of de novo non-tuberculous bacterial spinal infection. Method and Result:. Patients presenting to a single tertiary referral spinal centre between August 2011 and June 2014 were included in the study. 21 patients with nontuberculous bacterial infection were identified and included in the study. All patients were managed surgically with posterior stabilisation, with or without neural decompression, without debridement of the infected tissue. Neurological state was assessed using the frankel grading system before and after urgery. Long-term follow-up data was collected using SpineTango COMI questionnaires and Euro Qol EQ-5D system with a mean follow-up duration of 20 months postoperatively. The mean improvement in neurological deficits was 0.92 Frankel grade (range 0–4). At final followup, at a mean of 20 months, mean COMI score was 4.59, average VAS for back pain was 4.28. These symptoms were having no effect or only minor effect on the work or usual activities in 52%. 38% of patients reported a good quality of life. The average EQ-5D value was 0.569. There were no problems with mobility in 44% of patients. In 72% there were no problems with self-care. Conclusion:. Our study has shown that posterior surgery for the management of bacterial, nontuberculous spinal infection can improve neurological outcome in approximately half of the patients. However, at long term followup, only around 50% of patients was able to return their pre-morbid work or usual activities

Background: Pyogenic haematogenous spinal infection in the elderly, described as spondylodiscitis, vertebral osteomyelitis and epidural abscess is still considered a rare but life threatening condition. Objective: To test our hypothesis that low index of suspicion leads to delayed diagnosis. Late referral for definitive treatment may result in increased and perhaps avoidable medical morbidity, social and psychological drift, including early mortality. Method: Retrospective review of medical records over 10-year period. Patient pool obtained from theatre records, radiology and coding departments. Post-spinal operative infections and patients under 65 years old excluded. Initial presentation, admitting speciality, initial investigations and differential diagnosis, time to diagnosis, date and day of referral, mode of definitive treatment, pathologic entities, complications and outcomes were noted. Patient outcomes were measured as duration of treatment, length of hospital stay, complications, ambulatory status, complications, discharge destination and death. Outcomes were correlated with delayed diagnosis and referral. Results: Single largest series [n=46] of elderly [age> 65] patients with pyogenic spinal infections to our knowledge. Age ranged from 65–91 with mean of 71. 62% referral from Physician colleagues. Fever with malaise associated with chronic LBP was the commonest presenting complaint. 34 patients had discitis and 12 had epidural abscess. Time to diagnosis ranged from 2–17 days with mean of 8 days. Mean referral time to spinal team was 9 days with 39% referrals on Friday. Duration of hospital ranged from two weeks to three months. 46% required surgical decompression with four cases of related mortality during acute hospital stay. Conclusions: Time duration to Spinal referral had direct correlation with increase in morbidity, social and psychological drift, and mortality. The incidence of haematogenous spinal infection in the elderly has increased over the years in our series, contrary to popular belief. A high index of suspicion in elderly patients with PUO promotes early diagnosis and optimises outcome

The role of spinal instrumentation in the presence of infection is still controversial, radical debridement of infected vertebrae and disc material may leave the spine unstable despite the use of bone graft, and some form of spinal stabilisation may deem necessary. We reviewed 27 cases of primary pyogenic spinal infection treated in addition to an appropriate antimicrobial agents, by radical debridement, bone grafting and posterior (22) or anteror (5) spinal instrumentation. The indication for surgery was the failure of conservative treatment (4), progressive neurological deficit (20) and the lack of diagnosis (3). The infection was caused by pyogenic bacteria (19), Mycobacterium Tuberculosis (6), Candida Albicans (1) Echinococcus granulosus (1). The mean period of follow-up was 3.8 years (1–12). The infection was eradicated in all our patients, the neurological recovery was full in 19 out of 20 patients with neurological deficits. Deep wound infection (Three immunocompromised patients, they all responded to repeated wound debridement); implant failure (Two patients, both required revision of fixation), early postoperative death due to nosocomial infection (1). Spinal instrumentation may be indicated when after debridement and bone grafting, the stability of spine is compromised

Pyogenic haematogenous spinal infection in the elderly, described as spondylodiscitis, vertebral osteomyelitis and epidural abscess is considered a rare but life threatening condition. Our objective was to test the hypothesis that low index of suspicion leads to delayed diagnosis and referral for definitive treatment resulting in increased and perhaps avoidable medical morbidity, social drift including early mortality and to analyse pathological entities, complications and optimum treatment options. We performed a retrospective review of medical records over 10-year period. Post-operative infections and patients under 65 years old excluded. Initial presentation, investigations and differential diagnosis, time to diagnosis, date and day of referral, mode of definitive treatment, pathologic entities, complications and outcomes were noted. Patient outcomes were measured as duration of treatment, length of hospital stay, complications, ambulatory status, complications, discharge destination and death. Outcomes were correlated with delayed diagnosis and referral. 46 elderly (age> 65) patients with a mean age of 71 years (range=65–91). 62% referral from physicians. Fever with malaise associated with chronic LBP was the commonest presenting complaint. There were 31 patients with discitis, 12 epidural abscess and 3 osteomyelitis. Lumbar spine was affected in 63% patients. Time to diagnosis ranged from 2–17 days with mean of 8 days. Mean referral time was 9 days with 39% referrals on Friday. Staphylococcus aureus (47%) was the commonest organism isolated. Duration of hospitalisation ranged from two to twelve weeks. 46% required surgical decompression with four cases of related mortality during acute hospital stay. Time duration to spinal referral had direct correlation with increase in morbidity, social drift and mortality. The incidence of haematogenous spinal infection in the elderly has increased over the years in our series, contrary to popular belief. A high index of suspicion in elderly patients with PUO promotes early diagnosis and optimises outcome

To evaluate the efficacy of Vacuum Assisted Closure (VAC) in the management of post surgical spinal sepsis. A retrospective analysis was performed of patients with severe post operative spinal wound infections treated using a combination surgical debridement, antibiotics and VAC therapy. Full records were available for a total of twenty adult all of whom had had prior thoracic or lumbar instrumentation. Comorbidities included disseminated carcinomatosis (25 % of patients), Ankylosing spondylitis (5 %), rheumatoid arthritis (5%) and Polio (5%). In one patient there had been a prior history of irradiation of the surgical field. Most infections treated by this regime were identified within two weeks following surgery. At surgery infection deep to the dorso-lumbar fascia was found in 87 % of cases. It was possible to retain instrumentation in 60 % of cases. An average of three trips to theatre were required prior to wound closure, which was possible in 95 % of cases. The VAC device was left in situ for an average of 11 days. Complications included recurrence of infection necessitating further treatment in 20 % of cases, wound dehiscence necessitating healing by secondary intention in 5%, the need for free flap wound cover in 5 % and death from unrelated causes in 5%. VAC therapy may facilitate the management of wound sepsis following spinal surgery in susceptible patients allowing the maintenance of instrumentation and surgical correction

Spinal epidural sepsis is more widely recognised with MRI. Treatment includes antibiotics, multisystem support and drainage of pus. Neurological loss will often be stabilised but dramatic recovery is infrequent, explaining the importance of early intervention. This series highlights a very sinister spectrum of spinal infective disease despite ideal traditional treatment for spinal skeletal infection. This is a retrospective case series review of five patients. All patients presented with regional spinal pain, fever and regional musculoskeletal infective foci (e.g. discitis). Mild neurological abnormality existed in three patients. Rapid multisystem collapse occurred with the need for ventilatory support, despite institution of appropriate antibiotic treatment for all patients. All had grown Staphylococcus Aureus from blood cultures. Subsequent extensive quadriparesis/plegia developed, and repeat imaging demonstrated wide spread epidural pus in the cervical spine. Surgical treatment was considered but not performed when the prognosis was so poor neurologically and medically, and when the widespread epidural pus was so inaccessible. All patients died rapidly upon withdrawal of supportive treatment. This paper describes a sinister spectrum of spinal infection with catastrophic complications despite “appropriate” treatment for previously diagnosed spinal foci infection. Positive blood cultures and fever alert to these dangers, and multisystem collapse heralded the development of cervical epidural infection. Possible interventions include early MRI scanning of the whole spine, more aggressive (than traditionally accepted) surgical treatment of infective foci in the spine in these circumstances, and minimally invasive cervical canal decompression procedures with multiple laminotomies

Objective. Pyogenic spinal infection (PSI) is an increasingly common presentation to spinal units in the UK. Its investigation and diagnosis is often delayed. The purpose of this study was to determine the prognostic significance of the inflammatory marker levels on admission on achieving a positive microbiological diagnosis in patients with PSI. Study design. Retrospective case series review of all patients presenting with PSI to our unit. Subjects. Clinical data were collected on 96 consecutive patients diagnosed with a PSI over a 7-year period. Patient < 18 years at time of presentation or who had previous spinal surgery were excluded. Outcome Measures. Positive blood and/or tissue culture, and requirement for surgery. Continuous data were compared using the Wilcoxon rank-sum test∗∗ and logistical regression remodelling was assessed using the Spearman correlation∗. Categorical data was analysed using Fisher's exact test. ∗∗∗. Results. The C-reactive protein was statistically significant for; duration of preceding symptoms (p=0.0003)∗, isolation of a causative organism (p< 0.0001)∗∗, positive biopsy culture (p=0.0016)∗∗ and requirement for surgery (p=0.031)∗∗. The White Blood Cell (WBC) count was statistically significant for; duration of preceding symptoms (p< 0.0001)∗, isolation of a causative organism (p = 0.0003)∗∗, positive biopsy culture (p=0.0023)∗∗. The majority of patients who had a positive tissue culture had a positive blood culture (p< 0.0001)∗∗∗. Conclusion. The inflammatory marker levels on admission are a useful prognostic marker for isolating a causative organism in patients with PSI and help guide treating surgeons to whether proceeding to biopsy is likely to be a helpful investigation. Tissue biopsy in patients with PSI is only marginally superior to blood culture alone