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. Methods. 82 patients with spondylodiscitis were included prospectively from 01/2008. 28% of patients were treated conservatively (Group 1) and 72% operatively (Group 2). Clinical findings, SF-36, ODI, COMI, and a visual analog scale (VAS) were evaluated and compared between the groups at admission and follow-up (2 year FU). Results. Average patient age was 64.9 ± 6.3 years. Average inpatient hospital stay was 26.5 ± 16.9 days. Neurologic deficits were present in 39.0% of patients preoperatively and 18.3% at FU. Abscess formation was diagnosed in 89.0% of cases and intraspinal abscesses in 43.9%. Hospital mortality was 11.0% and total mortality 14.6% at FU. 6.1% of cases were lost to FU. The preoperative ODI scores averaged 75.4 ± 16.6, and did not vary significantly between the groups. At FU, with 33.9 ± 21.2, average score was significantly better (p<0.001). On the SF-36, preoperative average scores were PCS 25.7 ± 7.1 and MCS 37.3 ± 13.4, and at FU PCS 43.5 ± 10.1 (p<0.05) and MCS 47.7 ± 14.8 (p<0.05). COMI scores also showed significant (p<0.001) improvement (preoperatively 9.2 ± 1.0 and at FU 3.5 ± 2.2). On comparison, patients in Group 2 (VAS 8.3) preoperatively had more pain (p<0.05) than those in Group 1 (VAS 6.3), but there was no significant difference at FU (group 2 VAS 2.5 and group 1 VAS 3.0). Over 90% of operated patients reported that treatment helped, while over 30% of conservatively treated patients said that treatment helped a little or not at all. Discussion. In the pre-antibiotics era, the prognosis for spondylodiscitis was poor. Currently, it can still lead to serious health problems and become life threatening. Quality of life and physical limitations are markedly worse than for the general population. Compared to patients treated conservatively, patients treated with surgery have somewhat improved quality of life and significantly better patient satisfaction

PURPOSE OF THE STUDY. The anterior approach to the thoracic and lumbar spine is used with increasing frequency for various indications. With the advent of prosthetic intervertebral disc replacement, its use has become even more frequent and has often been associated with serious complications. The aim of this study was to evaluate vascular complications in patients who underwent anterior spinal surgery of the thoracic and lumbar spine. MATERIAL. We performed a total of 531 operations of the thoracolumbar spine from the anterior approach. In 12 cases, after exposure of the body of the first or second thoracic vertebrae, we employed the Smith-Robinson technique to expose the cervical spine. We used sternotomy in six, posterolateral thoracotomy in 209, pararectal retroperitoneal approach in 239, anterolateral lumbotomy in 58 and the transperitoneal approach in seven patients. The aim of surgery was somatectomy in 190 patients and discectomy in 341 patients. Sternotomy and transperitoneal approaches were carried out by a thoracic or vascular surgeon and all the other procedures were done by the first author. The indications for spinal surgery included an accident in 171, tumour in 56, spondylodiscitis in 43 and a degenerative disease in 261 patients. METHODS. The Smith-Robinson approach was used for exposure of T1 or T2. Sternotomy was indicated for treatment of T2–T4 and also T1 in the patients with a short, thick neck. Access to T3–L1 was gained by posterolateral thoracotomy, in most cases performed as a minimally invasive transpleural procedure. For access to the lumbar spine we usually used the retroperitoneal approach from a pararectal incision or lumbotomy. We preferred the pararectal retroperitoneal approach in L2–S1 degenerative disease, L5 fractures, and L5–S1 spondylodiscitis. We carried out lumbotomy in patients with trauma, tumors and L1–L4 spondylodiscitis. The transperitoneal approach from lower middle laparotomy was used only in tumors at L5 or L4. The patients were followed up for 2 to 96 months (average, 31.4 months) after anterior spinal surgery. RESULTS. In 12 patients treated by the Smith-Robinson procedure and in six patients undergoing sternotomy, neither early nor late signs of any injury to major blood vessels or internal organs were recorded. The 209 patients with posterolateral thoracotomy were also free from any signs of vascular injury, but trauma to the thoracic duet was recorded in one case. We found injury to major blood vessels in three patients in the group treated by the pararectal retroperitoneal procedure. In the total of 531 anterior spinal surgery procedures this accounts for 0.56 %; of the 304 lumbar operations and 239 pararectal retroperitoneal operations it is 0.99 % and 1.26 %, respectively. In one patient the vascular injury was associated with trauma to the ureter. CONCLUSIONS. The technique of anterior approach is safe only in the hands of experienced spinal surgeons with long experience. In institutions where anterior spinal surgery is not a routine method it is advisable to involve a vascular or cardiac surgeon. However, the most important point is to know when not to operate

Introduction. Degenerative disc disease results from mechanical alteration of the intervertebral disc. Biochemical modifications of the nucleus matrix are also incriminated. Furthermore, genetic predispositions as well as vascular factors have been advocated in the process of disc degeneration. A relationship between sciatica and Propionibacterium acnes has been described. However, it remains unclear if the hypothesis of a subclinical spondylodiscitis might play a role in the pathophysiology of degenerative disc disease. The purpose of this study was to analyze the possible presence of bacteria in lumbar discs of patients with degenerative disc disease. Methods. We prospectively analyzed the presence of bacteria in 83 patients (34 males and 49 females, average age 41 years) treated by lumbar disc replacement at L3-L4, L4-L5 or L5-S1. An intraoperative biopsy and microbiological culture were performed for each disc to determine if intradiscal bacteria were present. Great care was taken to avoid any source of contamination during the conditioning process of the biopsy. Microbiological results were compared to the magnetic resonance stages of disc degeneration according to the Pfirrmann and Modic classifications. Possible sources of previous iatrogenic disc contamination after discography or nucleotomy were analyzed. Results. The magnetic resonance stages were Pfirrmann IV or V, with Modic I signs in 32 and Modic II in 25 cases. A preoperative discography was performed in 49 patients, and 24 had previous nucleotomy. Germs were found in 40 discs, 43 cultures were steriles. The following bacteria were evidenced: Propionibacterium acnes 18, Staphylococcus coagulase negative 16, Staphylococcus aureus 3, Gram negative bacilli 3, Micrococcus 3, Corynebacterium 3, others 5. Ten biopsies presented several different germs. Bacteria were predominantly found in males (p=0.012). The mostly positive level was L4-L5 (p=0.075). Histological examination of 31 discs found inflammatory cells in 33 % of the biopsies with positive bacterial culture, versus 5 % of the sterile biopsies (p=0.038). There was no significant relationship between bacterial evidence and Modic sign. A preoperative discography or previous nucleotomies did not represent significant contamination sources. None of the patients presented clinical signs of infection. Conclusions. The finding of bacteria in 48 % of disc biopsies, presence of inflammatory cells at histological examination, the absence of responsibility of the discography as a factor of contamination, and the absence of clinical post-operative infection, defend the hypothesis of a low-grade spondylodiscitis which might play a role in the pathophysiology of degenerative disc disease. On the other hand, the presence of skin commensal bacteria, of ¼ of polymicrobial biopsies, and the fact that previous nucleotomy doesn't seem to be involved in inoculation, cannot allow to eliminate a contamination of the samples. Further studies are necessary to elucidate the responsability of intradiscal bacteria in degenerative disc disease. This could influence our treatment strategy of back pain, which could be based in the future on antibiotics