Most of the studies in the literature identify spondylodiscitis as a challenge for the physician: symptoms are not specific and sub-acute/chronic presentation is common. The question of when surgery is indicated is a frequent matter of debate. We want to present and validate our flow chart for spinal infections diagnosis and treatment.

A retrospective review of 128 cases of spinal infections presenting over a 10-year period was performed. Medical records, imaging (X-Rays, MRI with gadolinium, Ga-67 and Tc-99 bone scan), laboratory test and bacteriology results of 128 patients from 1997 to 2006 were reviewed.

The average age of presentation was 55 years (median age: 61 years, range: between 1 and 88 years) of 53 females and 75 males. Only one level was interested in 22% of the cases. The cervical spine was affected in 6% of cases, the thoracic spine in 37%, and the lumbosacral spine in 57%. Soft tissues have been affected in 16% of the patients. CT guided trocar biopsies were performed in 80 patients, incisional biopsies in 10 patients, and excisional biopsy in 1 case. No complication occurred. The most represented microorganisms which were identified were Staphylococcus Aureus and Mycobacterium Tuberculosis. Conservative treatment alone (antibiotic therapy and bracing) was performed in 84 cases out of 128 (66%); Forty-four patients with either neurologic compromise or mechanical instability or those who were unresponsive to drugs and immobilisation were submitted to surgical treatment.

Late diagnosis may lead to spinal deformities, prolonged hospital stay and more expensive management of the patient. Appropriate treatment usually brings to resolution even if spinal infections are rare and often misdiagnosed. We suggest an easy-to-follow flow-chart for the diagnosis and treatment of spinal infections.

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.