Spinal infection with intraspinal abscess or empyema and acute myelopathy: comparative analysis of diagnostics, therapy, complications and outcome in primary care

Abstract

Introduction This study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account. Methods Patients were enrolled in an ambispective study (2012–2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan–Meier method and Cox regression. Results In total, 134 patients with a median (IQR) age of 72 (61–79) years were analyzed. Baseline characteristics were similar between the SCI (n = 55) and noSCI (n = 79). A higher percentage of endocarditis (9% vs. 0%; p = 0.03) was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group (e.g., urinary tract infection, pressure ulcers). Lethality risk factors were age (HR 1.09, 95% CI 1.02–1.16, p = 0.014), and empyema/abscess extension (≥ 3 infected spinal segments, HR 4.72, 95% CI 1.57–14.20, p = 0.006), dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%. Conclusion PSI + are associated with higher in-hospital mortality, particularly when multiple spinal segments are involved. However, survival is similar with (SCI) or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates.

Pyogenic Spondylodiscitis: Risk Factors for Therapeutic Failure and Recurrence

“…Notably, various surgical procedures are described in the literature, all lacking high-quality evidence. 5,16,22 Our results should be interpreted carefully considering several limitations of this study. The small number of participants may have reduced the power of the results.…”

“…The literature highlights the role of neurologic deficits and spinal cord compression as emergency medical conditions associated with a higher rate of disease complications, such as pressure ulcers, urinary tract infections, circulatory dysregulation, and poor functional outcomes. 5,14,17,22 We hypothesized that these factors might also decrease the chances of eradicating the infection by the possible extensive area of necrosis associated. Alternatively, it may be a marker for an advanced infectious process or increased organism virulence.…”

Conservative versus early surgical treatment in the management of pyogenic spondylodiscitis: a systematic review and meta-analysis

“…The bar plot is interrupted to allow for adequate visualisation of all data points.

Figure 3 ( A ) An Egger’s asymmetry plot of all data points included in the meta-analysis (n = 21 studies) 13 , 23 – 26 , 29 , 32 – 35 , 37 , 38 , 41 – 43 , 47 , 48 , 50 , 52 ; the x-axis represents the inverse of standard error, and the y-axis the standardized treatment effect (as z-score). Furthermore, at the top of the graph different parameters of heterogeneity, including I 2 , are shown.

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“…The antibiotic regimen was not specified in most studies 13 , 24 , 26 , 28 – 35 , 39 , 41 , 42 , 45 , 46 , 50 – 52 . Several studies mentioned that antibiotic therapy was targeted toward an isolated organism 23 , 37 , 40 , 43 , 47 , 49 . However, blood or tissue culture positivity rates ranged from 24 26 to 93% 51 meaning that in several cases, broad-spectrum antibiotics were required.…”

“…The most common operations performed were laminectomies, debridement surgeries, and decompression surgeries. Several different approaches were used for surgery, with a posterior approach being most referenced in 17 studies 13 , 24 , 25 , 28 , 30 , 31 , 37 , 39 , 40 , 43 , 45 – 49 , 51 , 52 , and an anterior approach in 13 studies 24 , 25 , 28 , 31 , 37 , 39 , 40 , 45 , 46 , 48 , 50 – 52 . The most common indication for surgery was the presence or worsening of a neurological deficit (n = 19 studies) 13 , 23 – 27 , 32 , 35 , 37 – 40 , 42 , 44 , 45 , 47 , 48 , 50 , 52 , followed by failure of conservative management with antibiotics (n = 12 studies) 23 – 27 , 29 , 35 , 35 , 37 , 44 , 50 , 50 .…”