Abstract
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.
Similar content being viewed by others
References
Allen RT, Lee YP, Stimson E, Garfin SR (2007) Bone morphogenetic protein-2 (BMP-2) in the treatment of pyogenic vertebral osteomyelitis. Spine (Phila Pa 1976) 32:2996–3006
Anderdoff JJ, Boeke EJ, Lazarus C (1987) Tuberculosis of the spine: Results of management of 300 patients. J R Coll Surg Edinb 39:218–221
Aoki Y, Yamagata M, Nakajima F, Ikeda Y, Shimizu K, Yoshihara M, Iwasaki J, Toyone T, Nakagawa K, Nakajima A, Takahashi K, Ohtori S (2010) Examining risk factors for posterior migration of fusion cages following transforaminal lumbar interbody fusion: a possible limitation of unilateral pedicle screw fixation. J Neurosurg Spine 13:381–387
Babhukar SS, Tayade WB, Sk B (1984) A typical spinal tuberculosis. J Bone Joint Surg Br 66:239–242
Bailey HL, Gabriel SM, Hodgson AR, Shin JS (1972) Tuberculosis of the spine in children: Operative findings and results in one hundred consecutive patients treated by removal of the lesion and anterior grafting. J Bone Joint Surg Am 54:1633–1657
Behari S, Nayak SR, Bhargava V, Banerji D, Chhabra DK, Jain VK (2003) Craneocervical tuberculosis: Protocol of surgical management. Neurosurgery 52:72–80
Capener N (1954) The evolution of lateral rachiotomy. J Bone Joint Surg 36:128–150
Carragee EJ (1997) Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 79:874–880
Colmenero JD, Jiménez-Mejías ME, Reguera JM, Palomino-Nicás J, Ruiz-Mesa JD, Márquez-Rivas J, Lozano A, Pachón J (2004) Tuberculous vertebral osteomyelitis in the new millennium: still a diagnostic and therapeutic challenge. Eur J Clin Microbiol Infect Dis 23:477–483
Corea JR, Tamimi TM (1987) Tuberculosis of the arch of the atlas: A case report. Spine (Phila Pa 1976) 12:608–612
Chen WH, Jiang LS, Dai LY (2007) Surgical treatment of pyogenic vertebral osteomyelitis with spinal instrumentation. Eur Spine J 16:1307–1316
Darouiche RO (2006) Spinal epidural abscess. N Engl J Med 355:2012–2020
de Lucas EM, Gonzalez MA, Gutierrez A et al (2009) CT-guided fine-needle aspiration in vertebral osteomyelitis: true usefulness of a common practice. Clin Rheumatol 28:315–320
Deyo RA, Nachemson A, Mirza SK (2004) Spinal-fusion surgery—the case for restraint. N Engl J Med 350:722–726
Enoch DA, Cargill JS, Laing R, Herbert S, Corrah TW, Brown NM (2008) Value of CT-guided biopsy in the diagnosis of septic discitis. J Clin Pathol 61:750–753
Euba G, Narváez JA, Nolla JM, Murillo O, Narváez J, Gómez-Vaquero C, Ariza J (2008) Long-term clinical and radiological magnetic resonance imaging outcome of abscess-associated spontaneous pyogenic vertebral osteomyelitis under conservative management. Semin Arthritis Rheum 38:28–40
Fellander M (1975) Paraplegia in spondylitis: Results of operative treatment. Paraplegia 13:75–88
Fountain SS, Hsu LC, Yau AC, Hodgson AR (1975) Progressive kyphosis following solid anterior spine fusion in children with tuberculosis of the spine: A long term study. J Bone Joint Surg Am 57:1104–1107
Frazier DD, Campbell DR, Garvey TA, Wiesel S, Bohlman HH, Eismont FJ (2001) Fungal infections of the spine. Report of eleven patients with long-term follow-up. J Bone Joint Surg Am 83:560–565
Garceau GJ, Brady TA (1950) Potts paraplegia. J Bone Joint Surg Am 32:87–95
Gasbarrini A, Boriani L, Nanni C, Zamparini E, Rorato G, Ghermandi R, Salvadori C, Allegri V, Bandiera S, Barbanti-Brodano G, Colangeli S, Corghi A, Terzi S, Babbi L, Amendola L, Cristini F, Marinacci G, Tumietto F, Ciminari R, Malaguti MC, Rimondi E, Difiore M, Bacchin R, Facchini F, Frugiuele J, Morigi A, Albisinni U, Bonarelli S, Fanti S, Viale P, Boriani S (2011) Spinal infection multidisciplinary management project (SIMP): from diagnosis to treatment guideline. Int J Immunopathol Pharmacol (Suppl 2):95–100
Gotuzzo E, Carrillo C, Guerra J, Llosa L (1986) An evaluation of diagnostic methods for brucellosis—the value of bone marrow culture. J Infect Dis 153:122–125
Gouliouris T, Aliyu SN, Brown MN (2010) Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother 65(Suppl 3):11–24
Govender S (2002) The outcome of allografts and anterior instrumentation in spinal tuberculosis. Clin Orthop 398:60–62
Guerado E, Fuerstenberg CH (2011) What bone graft substitutes should we use in post-traumatic spinal fusion? Injury Suppl 2:S64–S71
Guirguis AR (1967) Potts paraplegia. J Bone Joint Surg Br 49:658–667
Hadjipavlou AG, Katonis PK, Gaitanis IN, Muffoletto AJ, Tzermiadianos MN, Crow W (2004) Percutaneous transpedicular discectomy and drainage in pyogenic spondylodiscitis. Eur Spine J 13:707–713
Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ (2000) Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976) 25:1668–1679
Hirakawa A, Miyamoto K, Masuda T, Fukuta S, Hosoe H, Iinuma N, Iwai C, Nishimoto H, Shimizu K (2010) Surgical outcome of 2-stage (posterior and anterior) surgical treatment using spinal instrumentation for tuberculous spondylitis. J Spinal Disord Tech 23:133–138
Hodgson AR, Stock FE (1960) Anterior spine fusion for the treatment of tuberculosis of the spine: The operative findings and results of treatment in the first one hundred cases. J Bone Joint Surg Br 55:715–734
Hodgson AR, Yau A (1967) Pott's paraplegia: a classification based upon the living pathology. Paraplegia 5:1–16
Hsu LCS, Leong JCY (1984) Tuberculosis of the lower cervical spine (C2 to C7): A report on 40 cases. J Bone Joint Surg Br 66:1–5
Jensen AG, Espersen F, Skinhøj P, Rosdahl VT, Frimodt-Møller N (1997) Increasing frequency of vertebral osteomyelitis following Staphylococcus aureus bacteraemia in Denmark 1980–1990. J Infect 34:113–118
Jiménez-Mejías ME, de Dios CJ, Sánchez-Lora FJ, Palomino-Nicás J, Reguera JM, García de la Heras J, García-Ordoñez MA, Pachón J (1999) Postoperative spondylodiskitis: etiology, clinical findings, prognosis, and comparison with nonoperative pyogenic spondylodiskitis. Clin Infect Dis 29:339–345
Kemp HBS, Jackson JW, Shaw NC (1974) Laminectomy in paraplegia due to infective spondylosis. Br J Surg 61:66–72
Kepler CK, Rawlins BA (2010) Mesh cage reconstruction with autologous cancellous graft in anterior cervical discectomy and fusion. J Spinal Disord Tech 23:328–332
King DM, Mayo KM (1973) Infective lesions of the vertebral column. Clin Orthop 96:248–253
Kirkaldy-Willis WH, Thomas TG (1965) Anterior approaches in the diagnosis and treatment of infections of the vertebral bodies. J Bone Joint Surg Am 47:87–110
Korovessis P, Petsinis G, Koureas G, Iliopoulos P, Zacharatos S (2006) Anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia for septic spondylitis of thoracolumbar spine: is the use of titanium mesh cages safe? Spine (Phila Pa 1976) 31:1014–1019
Kuklo TR, Potter BK, Bell RS, Moquin RR, Rosner MK (2006) Single-stage treatment of pyogenic spinal infection with titanium mesh cages. J Spinal Disord Tech 19:376–382
Le Page L, Feydy A, Rillardon L, Dufour V, Le Hénanff A, Tubach F, Belmatoug N, Zarrouk V, Guigui P, Fantin B (2006) Spinal tuberculosis: a longitudinal study with clinical, laboratory, and imaging outcomes. Semin Arthritis Rheum 36:124–129
Liebergall M, Chaimsky G, Lowe J, Robin GC, Floman Y (1991) Pyogenic vertebral osteomyelitis with paralysis. Prognosis and treatment. Clin Orthop Relat Res 269:142–150
Lifeso RM, Weaver P, Harder EH (1985) Tuberculous spondylitis in adults. J Bone Joint Surg Am 67:1405–1413
Louw JA (1986) Spinal tuberculosis with neurologic deficit: Treatment with vascularized rib grafts, posterior osteotomies and fusion. J Bone Joint Surg Br 72:686–693
McHenry MC, Easley KA, Locker GA (2002) Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 34:1342–1350
Medical Research Council Working Party on Tuberculosis of the Spine (1978) A controlled trial of ambulatory treatment, debridement and anterior spinal fusion in the management of the tuberculosis of the spine: Studies in Vulawayo (Rhodesia) and in Hong Kong. J Bone Joint Surg Br 60:163–177
Medical Research Council Working Party on Tuberculosis of the Spine (1982) A 10 years assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of the tuberculosis of the spine in patients on standard chemotherapy in Hong-Kong. J Bone Joint Surg Br 64:393–398
Medical Research Council Working Party on Tuberculosis of the Spine (1978) A controlled trial of anterior spinal fusion and debridement in the surgical management of tuberculosis of the spine in patients on standard chemotherapy: A study in two centers in South Africa. Tubercle 59:79–105
Mehta JS, Bhojraj SY (2001) Tuberculosis of the thoracic spine: A classification based on the selection of surgical strategies. J Bone Joint Surg Br 83:859–863
Michel SC, Pfirrmann CW, Boos N, Hodler J (2006) CT-guided core biopsy of subchondral bone and intervertebral space in suspected spondylodiskitis. AJR Am J Roentgenol 186:977–980
Modic MT, Feiglin DH, Piraino DW, Boumphrey F, Weinstein MA, Duchesneau PM, Rehm S (1985) Vertebral osteomyelitis: assessment using MR. Radiology 157:157–166
Mondorf Y, Gaab MR, Oertel JM (2009) PEEK cage cervical ventral fusion in spondylodiscitis. Acta Neurochir (Wien) 151:1537–1541
Moon MS, Woo YK, Lee KS, Ha KY, Kim SS, Sun DH (1995) Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spine. Spine (Phila Pa 1976) 20:1910–1968
Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A (2009) Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum 39:10–17
National Institute of Clinical Excellence. Tuberculosis guide 33. http://guidance.nice.org.uk/CG33/Guidance/pdf/English. Accessed in March 2011
Oga M, Arizono T, Takasita M, Sugioka Y (1993) Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Spine (Phila Pa 1976) 18:1890–1894
Rajasekaran S, Shanmugasundaram TK (1987) Prediction of the angle of the gibbus deformity in tuberculosis of the spine. J Bone Joint Surg Am 69:503–509
Rajasekaran S, Soundarapandian S (1989) Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg Am 71:1314–1323
Rand C, Smith MA (1989) Anterior spinal tuberculosis: paraplegia following laminectomy. Ann R Coll Surg Engl 71:105–109
Reinhold M, Knop C, Beisse R, Audigé L, Kandziora F, Pizanis A, Pranzl R, Gercek E, Schultheiss M, Weckbach A, Bühren V, Blauth M (2010) Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery. Eur Spine J 25:1657–1676
Smith AJ, Arginteanu M, Moore F, Steinberger A, Camins M (2010) Increased incidence of cage migration and nonunion in instrumented transforaminal lumbar interbody fusion with bioabsorbable cages. J Neurosurg Spine 13:388–393
Societé de Pathologie Infectieuse de Langue Française (SPILF) (2007) Recommendations pour la pratique clinique. Spondylodiscites infectieuses primitives, et secondaires à un geste intra-discal, sans mise en place de matériel. Med Mal Infect 37:554–572
Staatz G, Adam GB, Keulers P, Vorwerk D, Günther RW (1988) Spondylodiskitic abscesses: CT-guided percutaneous catheter drainage. Radiology 208:363–367
Stumpe KD, Zanetti M, Weishaupt D, Hodler J, Boos N, Von Schulthess GK (2002) FDG positron emission tomography for differentiation of degenerative and infectious endplate abnormalities in the lumbar spine detected on MR imaging. AJR Am J Roentgenol 179:1151–1157
Takahashi H, Suguro T, Yokoyama Y, Iida Y, Terashima F, Wada A (2010) Effect of cage geometry on sagittal alignment after posterior lumbar interbody fusion for degenerative disc disease. J Orthop Surg (Hong Kong) 18:139–142
Turgut M (2001) Spinal tuberculosis (Potts disease): It s clinical presentation, surgical management and outcome: A survey study on 694 patients. Neurosurg Rev 24:8–13
Turunc T, Demiroglu YZ, Uncu H, Colakoglu S, Arslan H (2007) A comparative analysis of tuberculous, brucellar and pyogenic spontaneous spondylodiscitis patients. J Infect 55:158–163
Yang SC, Fu TS, Chen LH, Chen WJ, Tu YK (2008) Identifying pathogens of spondylodiscitis: percutaneous endoscopy or CT-guided biopsy. Clin Orthop Relat Res 466:3086–3092
Yau AC, Hsu LC, O'Brien JP, Hodgson AR (1974) Tuberculous kyphosis: correction with spinal osteotomy, halo pelvic distraction, and anterior posterior fusion. J Bone Joint Surg Am 56:1419–1434
Yilmaz C, Selek HY, Gürkan I, Erdemli B, Korkusuz Z (1999) Anterior instrumentation for the treatment of spinal tuberculosis. J Bone Joint Surg Am 81:1261–1267
Conflict of interest
The authors declare that they have no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Guerado, E., Cerván, A.M. Surgical treatment of spondylodiscitis. An update. International Orthopaedics (SICOT) 36, 413–420 (2012). https://doi.org/10.1007/s00264-011-1441-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00264-011-1441-1