Objective. To perform validation study of the E. Pola classification (2017) and to assess expert consensus on the diagnosis and treatment of infectious lesions of the spine in the national professional community.Material and Methods. A clinical and radiological database on 15 cases of infectious spondylitis, as well as the information about original article by Pola and a Russian translation of the classification and tactical tables from this article, were distributed to 408 orthopedic traumatologists, neurosurgeons and radiologists who have experience in treating patients with spinal pathology and whose data are available in the registers of the relevant professional associations of the Russian Federation. The coincidence/difference in the responses concerning the definition of lesion types and the choice of treatment tactics, as well as proposals for the use of classification were assessed.Results. Answers were obtained from 37 respondents from 11 regions of the Russian Federation. The general interobserver agreement index (Fleiss kappa) for all types of spondylodiscitis was 0.388 (95 % CI 0.374–0.402), including for lesion types: type A – 0.480 (95 % CI 0.460–0.499, type B – 0.300 (95 % CI 0.281–0.320), and type C – 0.399 (95 % CI 0.380–0.419). Agreement levels were higher among radiologists (type A – 0.486, type B – 0.484, and type C – 0.477), orthopedic traumatologists (type A – 0.474, type B – 0.380, and type C – 0.479), and specialists with clinical experience less than 10 years (type A – 0.550, type B – 0.318, and type C – 0.437). The pooled data for all 12 lesion subtypes showed general poor agreement (k = 0.247, CI 0.240–0.253), satisfactory level was found for B3.2 type (k = 0.561, CI 0.542–0.581), good agreement (k > 0.61) was achieved between orthopedic traumatologists for type B3.2 and between radiologists for B3.1 and B3.2 lesion types. Respondents refused to use basic treatment options for type A in 15.1 %, type B in 7.5 % and type C in 3.2 % of answers, while indicating the need for interventions through anterior approach in 24.7 %, 43.0 % and 46.2 %, respectively. Limitations of the classification use depending on the localization and etiology of spondylitis were noted. Authors recommended taking into account the presence of systemic inflammatory response syndrome, mandatory CT scanning, clarification of spinal instability criteria, and the addition of anterior surgical interventions to the treatment algorithm.Conclusion. The Pola classification of spondylodiscitis is currently considered the most successful for tactical algorithms and implementation in broad clinical practice for spondylodiscitis. However, at the stages of its clinical application, there is an unsatisfactory interobserver expert consensus on the types of lesions, and there are limitations related to the etiology, localization and severity of the disease. A modified classification taking into account the identified limitations and including anterior procedures in the tactical options is advisable.
Objective. To analyze the results of treatment of disseminated (polysegmental and multilevel) forms of hematogenous vertebral osteomyelitis (HVO) as compared with those of monosegmental and monovertebral lesions.Material and Methods. A retrospective analysis of a monocenter cohort of 266 patients with hematogenous osteomyelitis of the spine for 2006 to 2019 was carried out. Patients were divided into two groups: Group A (polysegmental and multilevel lesions) included 33 (12.4 %) patients and Group B (monosegmental and monovertebral lesions) – 233 (87.6 %) patients. The main examination methods were: clinical, radiological (standardized roentgenography, CT), MRI, microbiological, histological and statistical ones.Results. Comparison revealed that involvement of the cervical (p < 0.001) and thoracic (p = 0.014) spine was more typical for polysegmental and multilevel lesions. There was a tendency to the predominance of type A lesions according to the Pola classification in patients with local forms (p = 0.078) and to the increase in type C lesions in polysegmental and multilevel processes (p = 0.035). The number of neurological complications was higher in polysegmental and multilevel lesions (p = 0.003). There were no significant differences in the treatment results, the number of relapses and mortality rate between the compared groups.Conclusion. Lesions of the cervical and thoracic spine and the presence of a neurological deterioration are typical for multilevel and polysegmental HVO. The formation of a multilevel lesion in different regions of the spine with a gap of 2–4 weeks or more requires a separate implementation of the diagnostic algorithm, defining of classification criteria and differentiated treatment tactics for each focus.
Objective. To analyze the known classifications of infectious and inflammatory lesions of the cervical spine using the example of the author’s clinical material.Material and Methods. Data on the results of treatment of 24 patients with lesions of the cervical spine were analyzed. Classifications proposed by groups of authors led by L. Homagk (2016) E. Pola (2017), M. Akbar (2012) and H. Almansour (2020) were used for comparison.Results. Out of 24 patients with osteomyelitis of the cervical spine, monosegmental lesions were observed in 15, polysegmental – in 5, multilevel – in 2, and multilevel polysegmental lesions – in 2 cases. The C5–C6 segment was affected in 70.8 % of cases. Sepsis was diagnosed in 2 (8.3 %) patients. One case was not classified, as there was a lesion of the C1–C2 segment. The total number of neurological deficit was 16 (66.7 %). Twenty (83.3 %) patients were admitted with the acute form of the disease, and 4 (16.7 %) patients with the chronic form. Surgery was performed in 20 (83.3 %) patients. Hospital mortality was 8.3 % (n = 2), 91.7 % (n = 22) of patients recovered. The analysis of the classifications presented above was carried out, and proposals for their use were outlined.Conclusion. «New Classification of Pyogenic Spondylodiscitis» by Pola et al., a modified classification with specification of instability criteria and adaptation of surgical methods of treatment for the cervical spine allows applying it as the main treatment and diagnostic algorithm.
Study design Retrospective analysis of a single-center cohort of patients with pyogenic vertebral osteomyelitis. The purpose of the study was to review risk factors for perioperative complications and recurrences in patients diagnosed with hematogenous pyogenic vertebral osteomyelitis. Material and methods 141 inpatient records of hematogenous pyogenic vertebral osteomyelitis were reviewed at the Regional Clinical Hospital No. 2, Tyumen. Patients who developed complications, neurological deficits and recurrences were assigned to A group (n = 66), and those who did not included in B group (n = 75). Results Perioperative complications, recurrences, risk factors and neurological disorders that could develop with different treatment methods were explored. There was a greater risk of recurrences and a lower rate of neurological complications seen in chronic cases and drug addicts. There was a lower risk of intra- and postoperative complications seen in thoracic spine involvement, a greater risk of neurological deficit with involved cervical spine and a lower risk in the lumbar spine involvement. There was a lower risk of neurological disorders in type A and type B disorders, and a greater risk in type C disorders as categorized by E. Pola. There were no differences in recurrence rates among different types of involvement. HIV did not increase the risk of complications and relapses. Surgical site infection developed in 8.1 % cases of transpedicular fixation and in 6.9 % following ventral interventions. No correlation was observed between the recurrence and complication rate and the surgical methods used. Overall, recovery or stable remission was achieved in 88.6 % of cases after treatment of relapses. Conclusion Recurrences and complications were primarily caused by delayed diagnosis, co-morbidities and neurological deficits. No correlation was observed between the recurrence and complication rate and the surgical methods used. There was a greater risk of recurrences and a lower rate of neurological complications seen in chronic cases and drug addicts. Neurological disorders are common for cervical spine disorders. The risk of complications was dependent on the type of involvement as categorized by E. Pola. There was a lower risk of neurological disorders in type A and B disorders and a statistically greater risk in type C disorders.
Objective. To analyze lethal outcomes in patients with hematogenous vertebral osteomyelitis.Material and Methods. Study design: retrospective analysis of medical records. A total of 209 medical records of inpatients who underwent treatment for hematogenous vertebral osteomyelitis in 2006–2017 were analyzed. Out of them 68 patients (32.5 %) were treated conservatively, and 141 (67.5 %) – surgically. The risk factors for lethal outcomes were studied for various methods of treatment, and a statistical analysis was performed.Results. Hospital mortality (n = 9) was 4.3 %. In patients who died in hospital, average time for diagnosis making was 4 times less (p = 0.092). The main factors affecting mortality were diabetes mellitus (p = 0.033), type C lesion according to the Pola classification (p = 0.014) and age over 70 years (p = 0.006). To assess the relationship between hospital mortality and the revealed differences between the groups, a regression analysis was performed, which showed that factors associated with mortality were Pola type C.4 lesions (OR 9.73; 95 % CI 1.75–54.20), diabetes mellitus (OR 5.86; 95 % CI 1.14–30.15) and age over 70 years (OR 12.58; 95 % CI 2.50–63.34). The combination of these factors increased the likelihood of hospital mortality (p = 0.001). Sensitivity (77.8 %) and specificity (84.2 %) were calculated using the ROC curve. In the group with mortality, the comorbidity index (CCI) was significantly higher (≥4) than in the group without mortality (p = 0.002). With a CCI of 4 or more, the probability of hospital death increases significantly (OR 10.23; 95 % CI 2.06–50.82), p = 0.005. Long-term mortality was 4.3 % (n = 9), in 77.8 % of cases the cause was acute cardiovascular pathology, and no recurrence of vertebral osteomyelitis was detected.Conclusion. Hospital mortality was 4.3 %, and there was no mortality among patients treated conservatively. The main risk factors were diabetes mellitus, type C lesion according to Pola and age over 70 years. There was a significant mutual burdening of these factors (p = 0.001). With CCI ≥4, the probability of death is higher (p = 0.005).
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