Spinal Infection Multidisciplinary Management Project (SIMP): From Diagnosis to Treatment Guideline

Concept Spondylodiscitis refers to an infection affecting the intervertebral disk, the vertebral body or the posterior arch of the vertebra being aetiologically, pyogenic, granulomatous (tuberculosis, brucellosis, or fungal infection) or parasitic. Diagnosis Spondylodiscitis diagnosis is based on clinical symptoms, a combination of erythrocyte sedimentation rate with C-reactive protein (CRP) tests and, less useful, leukocytosis. Blood culture is also a very cost-effective method of identifying organisms. Plain radiographs are useful, however changes may take several months to appear. Radionuclide tests are currently less used; nevertheless, fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) shows encouraging results particularly when magnetic resonance images (MRI) are unconvincing in the distinction between degenerative changes and infection. MRI with gadolinium enhancement is the choice for image diagnosis. Management Medical management is usually the basis for treatment, alone or in combination with surgery. Surgical approach, either by endoscopy or open, is indicated for biopsy when clinical evolution is unsatisfactory and no micro-organism has been isolated, and also whenever a root, spinal cord or dural compression is seen on MRI; spinal instability or severe deformity are also clear indications for surgical treatment. Less invasive surgery either CT-scan guided or, particularly, by endoscopy has good results. However open surgery is still the standard. The anterior approach allows for anterior disc and bone debridement. The posterior approach is indicated when posterior elements are involved or in the presence of an epidural abscess. Although good results have been claimed, the use of instrumentation in the presence of an infected focus is controversial, as the use of cages or BMPs are.

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“…Surgical treatment of spinal infection requires a multidisciplinary approach, and guidelines for that have been developed [21,62].…”

Section: Surgical Managementmentioning

confidence: 99%

Surgical treatment of spondylodiscitis. An update

Guerado

Cerván

2012

International Orthopaedics (SICOT)

182

125

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“…Spondylodiscitis remains a life-threatening disease with a mortality rate of 2-20 % [10,11]. Although some therapeutic guidelines are available, treatment of spondylodiscitis is certainly not standardized and is mostly based on local preferences resulting in physician-related variability [12][13][14][15]. Conservative treatment, comprising of long-term antibiotics optionally combined with bed rest and/or an orthosis, appears to be the treatment of choice for the majority of the patients [3].…”

Section: Introductionmentioning

confidence: 99%

Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review

et al. 2015

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Background Spondylodiscitis is a spinal infection affecting primarily the intervertebral disk and the adjacent vertebral bodies. Currently many aspects of the treatment of pyogenic spondylodiscitis are still a matter of debate. Purpose The aim of this study was to review the currently available literature systematically to determine the outcome of patients with pyogenic spondylodiscitis for conservative and surgical treatment strategies. Methods A systematic electronic search of MEDLINE, EMBASE, Cochrane Collaboration, and Web of Science regarding the treatment of pyogenic spondylodiscitis was performed. Included articles were assessed on risk of bias according the Cochrane Handbook for Systematic Reviews of Interventions, and the quality of evidence and strength of recommendation was evaluated according the GRADE approach. Results 25 studies were included. Five studies had a high or moderate quality of evidence. One RCT suggest that 6 weeks of antibiotic treatment of pyogenic spondylodiscitis results in a similar outcome when compared to longer treatment duration. However, microorganism-specific studies suggest that at least 8 weeks of treatment is required for S. aureus and 8 weeks of Daptomycin for MRSA. The articles that described the outcome of surgical treatment strategies show that a large variety of surgical techniques can successfully treat spondylodiscitis. No additional long-term beneficial effect of surgical treatment could be shown in the studies comparing surgical versus antibiotic only treatment. Conclusion There is a strong level of recommendation for 6 weeks of antibiotic treatment in pyogenic spondylodiscitis although this has only been shown by one recent RCT. If surgical treatment is indicated, it has been suggested by two prospective studies with strong level of recommendation that an isolated anterior approach could result in a better clinical outcome.

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“…Leitlinien existieren nicht, die vorhandenen Therapieempfehlungen stützen sich auf Studien mit niedrigem Evidenzlevel [1,16]. Aktuelle Algorithmen sollen als Orientierungshilfe bei der richtigen Therapiewahl dienen [17,21,22] [2,25], Komplikationen wie Blutungen, Duraläsionen und Pneumothoraces müssen berücksichtigt werden [26]. Die Blutkultur erlaubt einen Erregernachweis in bis zu 78 % [25,27,28].…”

Section: Aktuelle Behandlungsstrategien Der Spondylodiszitis In Deutsunclassified

“…Die NC-Kliniken verwenden häufiger Kombinationstherapien. Betalaktamantibiotika werden von allen Teilnehmern häufig genutzt, obwohl sie nur mittelmäßig knochengängig sind [7,13,22]. Die Dauer der antimikrobiellen Therapie beträgt bei der Mehrzahl der Teilnehmer empfehlungsgerecht mindestens 8-12 Wochen [12,16].…”

Section: Aktuelle Behandlungsstrategien Der Spondylodiszitis In Deutsunclassified