Abstract
Background Cervical spondylodiscitis is a rare condition that easily causes neurological deficits. This study aimed to evaluate the safety and efficacy of anterior debridement and fusion (ADF) with plating for cervical spondylodiscitis.
Method We retrospectively analyzed the medical records of 24 patients who underwent ADF with plating and antibiotics for cervical spondylodiscitis at our institution from June 2005 to June 2023. The neurologic status was evaluated using the Japanese Orthopedic Association scoring system and Hirabayashi recovery rate. Radiological parameters were assessed, including C2 to C7 angle, angle and height of the fused segment, and fusion status.
Results Mean follow-up time was 50.1 (range 12–162) months. The Japanese Orthopedic Association score increased from 13.2 preoperatively to 15.8 at the final follow-up, with a mean Hirabayashi recovery rate of 79.3%. Recovery outcomes were excellent in 17 (70.8%) cases, good in 3 (12.5%), acceptable in 1 (4.2%), and unchanged in 3 (12.5%). Postoperative C2 to C7 angles and the angle and height of the fused segment were significantly improved compared with preoperative measures. However, height loss of the fused segments occurred in all cases during the follow-up period, especially in ADF with titanium mesh. One patient received revision with posterior fixation because of a pathological fracture in the cephalic vertebral body of the fused segment in the early postoperative phase. Infection resolution and solid bony fusion were achieved in all patients.
Conclusion ADF with plating can achieve satisfactory clinical outcomes for cervical spondylodiscitis.
Clinical Relevance Poor bone quality secondary to infection, excessive intraoperative cervical distraction, and the choice of fusion material may be associated with the loss of fused segmental height and angle, as well as potential instrumentation failure, after ADF with plating.
Level of Evidence 4.
- cervical spondylodiscitis
- anterior cervical debridement and fusion
- cervical plating
- complications
- safety
- stability
Introduction
Spondylodiscitis is a rare infection affecting the intervertebral disc space, adjacent vertebral endplates, and vertebral bodies.1–3 Its incidence has risen in recent years due to factors such as advanced age, malnutrition, diabetes mellitus, drug abuse, immunodeficiency, septicemia, chronic use of steroids, and others.3–5 While the thoracic and lumbar spine are frequently involved, cervical spine involvement is uncommon, accounting for only 4% to 19% of cases.2–6 In smaller studies conducted in countries like the USA and Italy, cervical spondylodiscitis accounts for 11% to 19% of spinal infections.2 Conversely, a German study of 827 patients with spinal infections found a 6% incidence of cervical spine involvement, primarily linked to pyogenic infections.6 In cervical spondylodiscitis, the C5/C6 level is the most commonly affected, whereas the C1/C2 level is rarely involved.5,7 Unfortunately, cervical spondylodiscitis easily develops into abscess formation, vertebral body destruction, and neurological deficits.3,4 Mortality rates of up to 21% have been reported in the literature.3,4 The early diagnosis of cervical spondylodiscitis is challenging due to its insidious presentation and variable courses,4,6,8,9 and its optimal treatment remains controversial.7,10–12
Although sensitive antibiotic therapy might be an option in the early stage of cervical spondylodiscitis,13 surgical intervention is necessary if conservative treatment fails, neurological compromise, or cervical instability occurs.2,8 Surgical treatment consists mainly of anterior, posterior, and combined anterior-posterior approaches,2,6 aiming to debride, decompress, and restore cervical stability.10,11 Because the anterior column of the cervical spine is mainly affected in these patients, anterior debridement and fusion (ADF) has become the preferred treatment modality.5,14 It usually involves the use of titanium plates and screws to rebuild or stabilize the cervical spine.13,15 The aim of this study is to retrospectively analyze the clinical outcomes of ADF with plating for cervical spondylodiscitis in our institution.
Methods
We reviewed the records of adult patients who underwent ADF with plating for cervical spondylodiscitis between January 2005 and June 2023. This spondylodiscitis was diagnosed by integrating clinical features, radiological findings, and microbiological or pathological outcomes. Only patients with microbiological or pathological evidence were included in the study. We excluded patients with iatrogenic spondylodiscitis. Demographics, neurological status, radiological results, laboratory findings, surgical procedures, and prognostic outcomes were collected. This study was approved by the Institutional Review Board (IRB) of Nanfang Hospital, Guangdong, China (IRB approval number: NFEC-2025–053).
Surgery was indicated in patients with failed medical treatment, intolerable neck pain, perivertebral or epidural abscess formation, progressive vertebral body and disc space destruction, localized kyphosis or instability, as well as neurological deficits. The surgical strategy consisted of adequate surgical debridement, disc space or osseous defect reconstruction, and cervical stability and alignment restoration. A fusion procedure was performed using an autologous iliac bone strut, polyetheretherketone (PEEK) cage, or titanium mesh. The surgical specimen was sent to the laboratory for microbiological and pathological evaluation. Postoperatively, a rigid cervical collar was applied for at least 12 weeks. These patients also received intravenous antibiotics for 6 to 8 weeks, followed by oral antibiotics until infection parameters returned to normal limits. Antibiotic selection was based on microbiological evidence or is empirical in cases with negative microbiology results.
Surgical outcomes were assessed based on the neurological status and radiological findings at the preoperative, immediately postoperative, and final follow-up visits. Neurological function was assessed using the Japanese Orthopedic Association (JOA) scores (maximum points of 17). The improvement rate was calculated using the Hirabayashi formula: (postoperative score − preoperative score)/(17 − preoperative score) × 100%.16 Recovery outcomes are classified as excellent (75%–100%), good (50%–74%), acceptable (25%–49%), unchanged (0%–24%), or deteriorating (negative points). Radiological parameters included the fused segmental height (FH), the fused segmental angle (FA), the C2 to C7 angle, and the fusion status. The specific measurements are illustrated in Figure 1.
Measurement of radiological parameters. The C2 to C7 angle is between the lower-end plates of C2 (A1) and C7 (A2). The segmental angle is between the fused segment’s upper-end plate (A3) and lower-end plate (A4). The segmental height is the distance (B) between the upper-end plate’s anterior margin and the fused segment’s lower-end plate.
Statistical analysis was performed using IBM SPSS (version 27.0; IBM Corp.). Variables were expressed as means ± SDs or frequency (percentages). Due to the longitudinal nature of measurements (preoperative/postoperative/final follow-up) and small sample size, the Friedman test with Dunn-Bonferroni post hoc analysis was employed for functional outcomes, including JOA score, C2 to C7 angle, fused segmental angle, and segmental height. Significant findings (P < 0.05) underwent pairwise analysis using Wilcoxon signed-rank tests with Bonferroni correction (adjusted α = 0.017). Categorical variables were presented as percentages with appropriate χ²/Fisher’s exact tests.
Results
A total of 24 patients were included in this study. There were 16 men (66.7%) and 8 women (33.3%) with a mean age of 55.6 years (range 28–78 years). The mean duration of signs and symptoms was 3.6 months (range, 2 days to 12.2 months). The average follow-up period was 50.1 months (range 12–162 months). Neck pain and sensory disturbance (i.e., numbness, radicular pain, and sensory deficit) were chief complaints in 19 (79.2%) and 21 (87.5%) patients, respectively. Furthermore, fever (11, 45.8%) and muscle weakness (12, 50.0%) were also common symptoms and signs. Preoperative white blood cell counts (WBC), C-reactive protein, and erythrocyte sedimentation rate were elevated in 5 (20.8%), 21 (87.5%), and 21 (87.5%) patients, respectively. However, 3 patients had normal C-reactive protein and erythrocyte sedimentation rate. Twenty-one patients had positive microbiological evidence by the bacterial cultures or next-generation sequencing outcomes. Mycobacterium tuberculosis was identified in 8 cases, Brucella spp. in 5 cases, Staphylococcus aureus in 2 cases, Staphylococcus epidermidis in 1 case, Escherichia coli in 2 cases, Salmonella in 1 case, Acinetobacter baumannii in 1 case, and Prevotella in 1 case, respectively. Despite pathological findings of spondylodiscitis, 3 cases still had negative microbiology results after intraoperative sample culture, blood culture, and next-generation sequencing test. The infections involved mainly the C6 to C7 segment, which was found in 10 patients (41.7%), followed by C4 to C5 and C5 to C6 segments in 9 patients (37.5%), respectively. Preoperative radiological examination revealed a multisegmental (≥3) infection of the cervical spine in 10 of 24 patients. Moreover, epidural abscesses were observed in 12 patients (50.0%) (Table 1).
Clinical presentation of patients undergoing anterior debridement and fusion.
Among the 24 patients, 15 (62.5%) had received antibiotic therapy within 1 month prior to admission. Of these 15 patients, 6 (40.0%) experienced progressive neurological deterioration following treatment, while the remaining 9 (60.0%) showed no significant clinical improvement. Empirical antibiotic therapy was initiated within 48 hours of admission in 22 patients (91.7%). Emergency surgical intervention was required in 2 cases (8.3%). Antibiotic regimens were subsequently adjusted based on intraoperative microbiological cultures or histopathological findings. The mean duration of postoperative antibiotic therapy was 27.8 weeks (Supplemental Table 1).
All patients were treated by ADF with plating. Fusions were performed by using structural autologous iliac bone grafts in 13 cases, PEEK cage with autografts in 6, titanium mesh with autografts in 4, and the combined use of cage and titanium mesh with autografts in 1. As shown in Table 2, the mean JOA score was 13.2 ± 3.5 at preoperative, 14.7 ± 3.0 at postoperative, and 15.8 ± 2.5 at the last follow-up, respectively (P < 0.001). The mean recovery rate was 79.3% (range 0%–100%). Recovery outcomes were excellent in 17 (70.8%) cases, good in 3 (12.5%), acceptable in 1 (4.2%), and unchanged in 3 (12.5%). Ten patients (41.7%) still experienced mild residual symptoms such as neck pain, sensory disturbance (i.e, numbness and sensory deficit), and motor weakness at the final follow-up. Radiological follow-up showed achievement of bone fusion in all patients (Figure 2). The overall radiological parameters are shown in Tables 3 and 4. The mean postoperative C2 to C7 angle and angle and height of the fused segment were significantly improved compared with those at preoperatively (Supplemental Table 2). However, the height and angle of the fused segment frequently decreased during follow-up (Supplemental Figure 1, Supplemental Table 2). A greater degree of height loss of the fused segment was observed in ADF with titanium mesh than in ADF with autologous iliac bone or PEEK cage. The fused height loss of >3 mm was defined as implant subsidence.17 Subsidence occurred in 2 cases with titanium mesh implants and 1 case with a PEEK cage. Furthermore, 1 patient received revision surgery with posterior fixation due to a pathological fracture in the cephalic vertebral body of a fused segment in the early postoperative phase (Figure 3).
Case 1. Pre- and postoperative radiological images of a 52-y-old male patient with intractable neck pain, as well as sensory deficit and motor weakness in the left extremity for 1 y. (A–D) Preoperative images show destruction of the C5 to C6 vertebral body, intervertebral space narrowing, and epidural abscess formation (yellow arrow). (E and F) Thorough debridement, decompression, and fusion with iliac bone graft. (G) Intraoperative radiograph. (H) Postoperative radiographs suggest stable internal fixation. (I and J) X-ray and computed tomography images at the 12 mo follow-up. (K) Final radiographic follow-up (36 mo) demonstrated bone fusion and maintained spinal alignment.
Case 2. Pre- and postoperative radiological images of a 65-y-old male patient with intractable neck and shoulder pain, as well as numbness and pain in both upper limbs for more than 6 mo. (A and B) At admission, the C5 to C6 vertebral body was destroyed, with narrowing of the vertebral space, hypodensity mapping, and peripheral hyper-osteogeny (yellow arrows). (C) Mixed signals of the C5 to C6 vertebral body were seen on T2 magnetic resonance imaging, with erosive destruction of the intervertebral endplates and spinal canal narrowing. (D) Intraoperative radiograph. (E) X-ray revealed a C5 vertebral fracture on day 4 after surgery (yellow arrows). (F) Intraoperative imaging for second-stage surgery. (G) Postoperative x-ray imaging confirmed stable posterior instrumentation with maintained fracture reduction. (H and I) Radiological images showed that the interbody had reached a fusion state, and the fracture line had disappeared at the 12 mo follow-up. (J) Computed tomography image at the final follow-up (30 mo).
Clinical characteristics after ADF with CP.
Radiological outcomes.
Radiological outcomes in different fusion modalities.
Discussion
Cervical spondylodiscitis is a rare and challenging condition. Many patients do not present infectious features such as fever or elevated WBC, and neck pain might be the most common symptom in the early stages of the disease.4–6,8,9,18 In our study, only 11 patients (45.8%) had a fever, and 5 (20.8%) had elevated WBC preoperatively. It is reported that C5/C6 is the main involved level, combined with a high rate of epidural abscesses.3,5,8 The cervical spine allows a wide range of motion, and the cervical cord occupies a large portion of the spinal canal. In contrast with spondylodiscitis in other regions, cervical spondylodiscitis often manifests with a relatively more rapid neurological decline, leading to increased mortality.3,5,8 The most frequently affected level in our series was C6/C7, and 41.7% of the cases presented multisegment involvement. Furthermore, 50.0% of cases were associated with epidural abscess formation, and neurological impairment was found in 95.8% of cases. Similarly, a high incidence of neurological deficits has also been found in our literature review.3,5,7,8 Due to its potentially devastating complications, early diagnosis and prompt treatment are crucial for achieving good results in cervical spondylodiscitis.
Although the combination of antibiotic therapy and external immobilization enabled nonsurgical management in the early stage of this disease, some patients still suffer from rapid neurological deterioration.15,19 Surgery is indicated in cases with structural instability, neurological impairment, and absence of clinical improvement.19 Surgical management should include debridement, decompression, alignment restoration, and spinal stabilization.10,11 Spondylodiscitis mainly affects the anterior part of the cervical spine, whereas the posterior elements are rarely involved.14 Anterior surgery for cervical spondylodiscitis can offer several advantages, such as radical debridement of necrotic tissue, direct relief of anterior compression, correction of segmental kyphosis, and obtaining an adequate sample collection for accurate bacteriological examination.13,15 Instrumentations contribute to better correction of kyphosis, earlier fusion, and maintenance of sagittal alignment, and they are thought to be safe in infectious cases.13 After ADF with plating followed by antibiotic coverage, the infection resolution and no infection recurrences were observed in all our patients, and satisfactory neurological improvement occurred in most patients (acceptable and above: 21/24, 87.5%). The mean Hirabayashi recovery rate was 79.3% at the final follow-up, which is similar to results from other reported series.20,21 Therefore, anterior surgery is associated with favorable neurological outcomes in patients with cervical spondylodiscitis.
Anterior column reconstruction after debridement is often conducted by multiple fusion techniques, including autologous iliac bone graft, PEEK cage filled with autograft, titanium mesh filled with autograft, allografts, or bone substitutes.8,15 In this study, we used autograft (tricortical iliac or cancellous) in the interbody space, and solid bony fusion was achieved in all patients. Postoperative radiological parameters, including fused segmental height, fused segmental angle, and C2 to C7 angle, were improved compared with preoperative. However, the height loss of the fused segments occurred in all cases during the follow-up period, especially in ADF with titanium mesh. The less contact area with the endplate and subsequent localized high stress can explain why fusion with titanium mesh exhibits greater fused height loss and higher subsidence rates than autologous iliac bone or PEEK cage.22 Overdistraction of the intervertebral space and excessive length of the implant have also been reported to be associated with height loss of the fused segments and implant subsidence.23 Importantly, the poor bony quality, osteomyelitis, and irregular end plates are thought to be the major cause of postoperative fused height loss and implant subsidence.15 Although fused segment height loss does not reduce fusion rates or affect short-term clinical outcomes, anterior cervical plating and postoperative external fixation should be taken to provide biomechanical stability, achieve better bone fusion, and prevent sagittal malalignment.
Early postoperative screw loosening and plate dislocation have been frequently reported in cases of cervical spondylodiscitis.3,10,19 It is generally accepted that the poor bone quality caused by the infection is the key contributor to the fixation failure after anterior surgery.15 Once there is serious doubt about the loosening of the instrumentation, additional posterior fixation should be performed as soon as possible.15 In serious conditions, the removal of the anterior plate and the application of a new graft should be considered simultaneously.2 Significant loosening of the instrumentation was not observed in our patients. Unfortunately, 1 patient in our series had a fracture of the cephalic vertebral body in the fused segment in the early postoperative phase and received revision surgery by additional posterior fixation with lateral mass screws (Figure 3). This patient underwent anterior debridement, corpectomy of C6, autologous iliac bone graft, and ventral plating. Improvement of neck pain and neurological status was achieved postoperatively, but recurrent neck pain occurred on day 4 after anterior surgery. The radiograph showed a C5 vertebral fracture and loss of the fused segment height. Apart from poor bone quality, another possible reason for this complication is that the length of the bone graft might be excessive, resulting in increased biomechanical loads on neighboring vertebral bodies.24
There are some limitations that should be addressed. First, the current evidence is weak due to a single-center retrospective study with a small sample. Second, cases with pyogenic and non-pyogenic (tuberculosis or brucellosis) infections were included in this study, resulting in a lack of consistency. However, cervical spondylodiscitis is very rare, and most of these reports included a limited number of cases.2,6,8,13,15 Therefore, a multicenter study should be conducted by enrolling a large sample size, and subgroup analysis of pyogenic and non-pyogenic cases might be necessary.
Conclusion
The findings of this study provide evidence that ADF with plating is associated with satisfactory neurological improvement, restoration of spinal stability, and a high rate of fusion in patients with cervical spondylodiscitis. Postoperative height or angle loss of the fused segments was a prevalent radiographic finding. Future studies should include larger sample sizes and stratify infection types to further validate these conclusions.
Supplementary material
FIGURE S1.
TABLE S1.
TABLE S2.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Ethical Statement This retrospective study analyzed de-identified data from imaging databases and clinical archives. The Institutional Review Board of Nanfang Hospital, Guangdong, China (IRB No. NFEC-2025-053) approved the research protocol. Informed consent was waived due to the retrospective design and use of anonymized data, which posed minimal risk to participants. The study was conducted in strict compliance with the Declaration of Helsinki (2013 version).
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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