A Staged Treatment Algorithm for Spinal Infections

Abstract

Background and Study Aim?Spinal pyogenic infections occur frequently in today's neurosurgical routine. Conservative therapy often proves to be insufficient against an aggressive disease that affects patients who tend to be elderly and debilitated with complex comorbidity. Treatment, or lack of treatment, carries risks of persistent disability, sepsis, and death. In this study, we propose a tailored and staged algorithm for treating such spinal infections and present results of this approach. Patients and Methods?We retrospectively analyzed 52 patients (33 male, 19 female; median age: 68 years) who had undergone cervical, thoracic, or lumbar surgery for spinal infections according to the proposed staged treatment algorithm. Results?Most of the 52 patients were severely disabled (35% with quadri- or paraparesis, 31% with sepsis and catecholamine dependency, 17% with a single motor deficit, and 10% with meningitis). We surgically treated multilevel and multisegmental spinal infections via 23 nonstabilizing and 57 stabilizing ventral or dorsal approaches to the cervical, thoracic, or lumbar spine. The mean follow-up time was 24 months. Overall mortality was 19%. Surgery-related complications occurred in 11.5% of patients; recurrence of infection occurred in 3.8%. Motor function improved in 61.7%; bladder and sphincter dysfunction remitted completely in 50.0%. Conclusions?Depending on the patient's health status and neurological condition, surgery in complex spinal infections provides a good outcome in most cases. Nevertheless, indication must be individualized; for this, the proposed algorithm seems to be an excellent tool. We find that surgery should be discussed as a treatment of first choice for today's often complex spinal infections.

Management of spinal infection: a review of the literature

“…Conservative cases seem to be followed by mechanical back pain more often than surgical cases [ 67 ] and develop more deformity at long term. This comes at a price, as perioperative complication rates are higher in surgically treated cases, although overall mortality is lower in operated patients [ 78 ]. Delayed (surgical) treatment entails significantly poorer surgical outcome [ 4 , 19 ].…”

“…Algorithms like in Fig. 5 have been reported [ 3 , 78 ]. Among others, the optimal duration for antimicrobial treatment is still unclear, in surgical as in solely conservative treatment.…”

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Fig. 5 Operative treatment algorithm for SI, modified according to Stuer et al and Hadjipavlou et al [ 37 , 78 ]

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“…4 ) [ 21 ]. Percutaneous pedicle screw instrumentation (1) without any debridement [ 21 ], (2) with minimally invasive decompression and debridement, or (3) with a second anterolateral debridement/corpectomy is increasingly used [ 78 ].…”

“…The incidence varies between 1:20,000 and 1:100,000, and mortality rates range between 2 and 20% in developed countries [ 1 , 7 , 44 , 70 ]. However, the incidence of SI has been increasing in the last decades [ 78 ]. This may be related to improving imaging techniques and clinical diagnostics, to the progressive number of older patients suffering from chronic diseases, to an increased amount of intravenous drug abusers, and to the growing number of spinal surgery and instrumentation [ 17 ].…”