Abstract
Background Despite common conservative management for spondylodiscitis, surgical intervention is indicated in specific clinical scenarios. While open techniques are traditionally favored, the role and efficacy of minimally invasive surgery (MIS) vs conventional open approaches remain actively debated.
Methods A Preferred Reporting Items for Systematic Reviews and Meta-Analyses–compliant systematic review and meta-analysis identified studies comparing MIS and open techniques for spondylodiscitis from PubMed, Embase, and Cochrane. The primary outcome was postoperative pain score. Secondary outcomes included wound revision rates, intraoperative blood loss, hospital stay, operative time, and postoperative C-reactive protein/white blood cell levels. Statistical analysis utilized RevMan 5.1.7; heterogeneity was assessed via I².
Results Eleven observational studies (933 patients; 432 MIS) were included. MIS showed superiority in postoperative pain scores (standardized mean difference: −1.03; 95% CI: −1.73 to −0.33; P = 0.004) and lower wound revision rates (OR: 0.46; 95% CI: 0.23–0.89; P = 0.020). Intraoperatively, MIS provided reduced blood loss (mean difference [MD]: −321.27 mL; 95% CI: −407.35 to −247.79; P < 0.0001) and shorter operative time (MD: −32.47 minutes; 95% CI: −47.12 to −17.83; P < 0.0001). Postoperatively, MIS resulted in shorter hospital stay (MD: −3.96 days; 95% CI: −5.30 to −2.62; P < 0.0001), lower C-reactive protein (MD: −0.40; 95% CI: −1.73 to 0.93; P = 0.56), and reduced white blood cell counts (MD: −0.75; 95% CI: −0.98 to −0.52; P < 0.0001).
Conclusion Our findings suggest that MIS offers significant advantages over open techniques for spondylodiscitis, representing a valuable and effective management option.
Clinical Relevance For appropriately selected patients with spondylodiscitis requiring surgical treatment, minimally invasive techniques may offer meaningful perioperative advantages over conventional open surgery, including reduced postoperative pain, wound revision rates, blood loss, operative time, and hospital stay. These findings support MIS as a valuable surgical option, particularly when minimizing surgical morbidity is a priority.
Level of Evidence 3.
Introduction
Pyogenic spondylodiscitis is a serious spinal infection associated with severe pain, neurological deficits, and the risk of progressive instability. Its incidence has been increasing in aging populations and in patients with immunosuppressive comorbidities.1,2 Current guidelines recommend targeted antibiotic therapy, and surgical intervention is typically indicated in the presence of progressive neurological deficits, spinal instability, epidural or paravertebral abscess formation, failure of antibiotic therapy, or intractable pain. The choice of surgical approach is influenced by multiple factors, including the anatomical location of the infection, extent of vertebral destruction, presence of deformity, and patient comorbidities. While open approaches are traditionally preferred in cases requiring extensive debridement and reconstruction, minimally invasive techniques have been increasingly adopted in selected patients with limited instability and preserved anatomical planes. However, they do not define a single “gold standard” surgical technique.1
Traditionally, surgical management has relied on open anterior or combined anterior–posterior approaches for thorough debridement and stabilization. However, minimally invasive surgery (MIS) techniques—including percutaneous pedicle screw fixation, tubular or oblique interbody approaches, and percutaneous or endoscopic debridement—have emerged as attractive alternatives, offering the potential for reduced blood loss, decreased postoperative pain, and shorter hospital stays while achieving comparable infection control and neurological outcomes.3–5 Despite these advantages, the current evidence remains heterogeneous and largely derived from retrospective cohorts, with methodological limitations that preclude definitive conclusions.6,7
Recent systematic reviews and meta-analyses suggest that MIS approaches may reduce intraoperative blood loss, operative time, and length of hospital stay compared with open surgery, without compromising infection eradication or long-term neurological recovery.6,7 Nevertheless, the available studies are limited by small sample sizes, heterogeneity of surgical techniques, and variability in patient selection. Moreover, there remains uncertainty regarding whether the potential benefits of MIS translate across specific patient subgroups, such as frail elderly patients or those with severe deformity and instability.8,9 Evidence also indicates that surgical intervention in general may lower mortality and recurrence compared with medical management alone in selected patients, but the impact of surgical approach—open vs MIS—on these critical outcomes remains unclear.10
The aim of the present study was to perform a systematic review and meta-analysis to compare open surgery and minimally invasive techniques for the treatment of pyogenic spondylodiscitis. The outcomes of interest included postoperative pain scores, wound revision rates, intraoperative blood loss, operative time, length of hospital stay, and postoperative inflammatory markers, specifically C-reactive protein (CRP) levels and white blood cell (WBC) counts.6,7
Methods
Search Strategy and Selection Criteria
This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.11 A comprehensive search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was performed from inception to 1 July 2025 and was restricted to articles published in English. The search strategy incorporated the following terms and their combinations: “spondylodiscitis,” “pyogenic spondylodiscitis,” “spinal infection,” “open surgery,” “conventional surgery,” “minimally invasive surgery,” “MIS,” “percutaneous fixation,” “endoscopic debridement,” and “percutaneous surgery.” Reference lists of eligible studies and relevant reviews were also screened to ensure that no additional publications were overlooked.
Eligible studies included randomized controlled trials (RCTs) and observational studies directly comparing minimally invasive and open surgical techniques for the treatment of pyogenic spondylodiscitis, provided they reported at least 1 of the predefined outcomes of interest. Studies were excluded if they involved overlapping patient populations, lacked a direct comparison between minimally invasive and open approaches, or failed to provide relevant perioperative or clinical outcome data.
Definition of MIS
For the purposes of this study, MIS techniques were defined as surgical approaches that minimize soft tissue disruption through percutaneous or limited-access corridors. These included percutaneous pedicle screw fixation, endoscopic debridement, and tubular or mini-open approaches. Conventional open surgery was defined as techniques involving extensive muscle dissection and direct wide exposure of the spinal structures.
Outcomes Assessed
The primary outcome of interest was the postoperative pain score, evaluated using validated instruments such as the visual analog scale, numerical rating scale, or other equivalent measures. Secondary outcomes comprised wound revision rates, intraoperative blood loss, operative time, length of hospital stay, and postoperative inflammatory markers, specifically CRP levels and WBC counts.
Data Analysis
Two reviewers independently extracted baseline characteristics and outcomes data using a standardized form based on prespecified criteria. Any discrepancies were resolved by consensus. For dichotomous outcomes, treatment effects were expressed as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Continuous outcomes were summarized as mean differences (MDs) with 95% CI. Statistical heterogeneity among studies was assessed using the Cochran Q test and quantified with the I² statistic, with a P value of <0.10 and an I² greater than 25% considered indicative of significant heterogeneity. Data were pooled using the DerSimonian and Laird random-effects model. All statistical analyses were performed with Review Manager software (RevMan, version 5.1.7, The Cochrane Collaboration, Oxford, UK).
Quality Assessment
The risk of bias for RCTs was evaluated using the Cochrane Risk of Bias 2 tool,8 which assesses 5 domains: randomization process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selection of reported results. Each domain was judged as presenting a low risk of bias, some concerns, or a high risk of bias, leading to an overall risk of bias judgment for each trial. Nonrandomized studies were appraised using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool,9 which evaluates 7 domains including confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selection of reported results. Each domain was classified as having low, moderate, serious, or critical risk of bias, and an overall judgment was assigned accordingly. All assessments were performed independently by 2 reviewers, with disagreements resolved through discussion and consensus.
Results
Study Selection and Characteristics
As detailed in Figure 1, the initial search yielded 393 results. After removal of duplicate records and ineligible studies, 24 results remained and were fully reviewed based on inclusion criteria. Of these, a total of 11 studies were included, comprising 933 patients from observational studies; no RCT was found in this search. A total of 432 (46%) patients received MIS procedures, and 501 (54%) patients received open surgery. Study characteristics are reported in the Table. Three studies employed endoscopic debridement techniques, while 1 study used percutaneous screw fixation for arthrodesis assisted by a robotic system. Considerable variability was observed in the mean age of study participants, in sex distribution, and in the number of patients with comorbidities (Table).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram detailing study screening and selection process.
Characteristics of included studies.
Clinical Outcomes
In the analysis of clinical outcomes, we evaluated all measures reflecting the patient’s condition and disease control after surgery. Among these, postoperative pain scores measured with the visual analog scale favored MIS over open surgery, although between-study heterogeneity was high (standardized mean difference: −1.03; 95% CI: −1.73 to −0.33; P = 0.004; I² = 89%; Figure 2A). In addition, length of hospital stay was shorter for patients undergoing minimally invasive procedures compared with those treated with open surgery (MD: −3.96 days; 95% CI: −5.30 to −2.62; P < 0.0001; I² = 0%; Figure 2B). Regarding the need for wound revision, there was a lower incidence among patients treated with less invasive techniques compared with the conventional approach (OR: 0.46; 95% CI: 0.23–0.89; P = 0.020; I² = 0%; Figure 2C).
(A) Forest plot comparing postoperative pain scores between minimally invasive surgery (MIS) and conventional open techniques. (B) Forest plot comparing length of hospital stay between MIS and open techniques. (C) Forest plot comparing the rate of wound revision surgery between MIS and open techniques.
Intraoperative Outcomes
We also examined outcomes directly related to the surgical procedure. Minimally invasive procedures were superior to open surgery with respect to intraoperative blood loss (MD: −321.27 mL; 95% CI: −407.35 to −247.79; P < 0.0001; I² = 78%; Figure 3A). Operative time was likewise evaluated and again favored MIS (MD: −32.47 minutes; 95% CI: −47.12 to −17.83; P < 0.0001; I² = 84%; Figure 3B), albeit with high heterogeneity. This heterogeneity is likely attributable to the lack of standardization and limited description of how intraoperative blood loss was measured, as well as the absence of reported standard deviations in some included studies.
(A) Forest plot comparing intraoperative blood loss between minimally invasive surgery (MIS) and open techniques. (B) Forest plot comparing operative time between MIS and open techniques.
Laboratory Outcomes of the Inflammatory Response
To complement the comparative analysis between techniques, we assessed postoperative inflammatory markers to explore potential links between clinical and laboratory improvements according to the surgical approach. Postoperative WBC counts were lower in patients who underwent MIS (MD: −0.75; 95% CI: −0.98 to −0.52; P < 0.0001; I² = 0%; Figure 4A). For CRP, postoperative values were also lower after minimally invasive techniques than after open surgery (MD: −0.40; 95% CI: −1.73 to 0.93; P = 0.56; I² = 80%; Figure 4B); however, this comparison showed high heterogeneity and did not reach statistical significance.
(A) Forest plot comparing postoperative white blood cell counts between minimally invasive surgery (MIS) and open techniques. (B) Forest plot comparing postoperative C-reactive protein levels between MIS and open techniques.
Quality Assessment
The risk of bias evaluation, conducted using the ROBINS-I tool, revealed specific concerns primarily related to the design of the included studies. All included studies were rated as having moderate risk of bias in the first domain (bias due to confounding). This rating reflects the nonrandomized nature of the studies, which limits the ability to control unmeasured confounders. Similarly, a moderate risk of bias was identified in the second domain (bias in the selection of participants) in several studies and was attributed to the lack of statistical methods to ensure baseline comparability between groups. As a result, the overall risk of bias was rated as low for 5 studies and moderate for the remaining 6.
Discussion
This systematic review and meta-analysis aimed to comprehensively compare outcomes between MIS and open surgery for pyogenic spondylodiscitis. Our findings demonstrate that MIS approaches are associated with significant advantages, including reduced postoperative pain, shorter hospital stays, and lower wound revision rates. Furthermore, MIS procedures consistently resulted in less intraoperative blood loss and shorter operative times, aligning with its purported benefits. While MIS also showed a favorable impact on postoperative WBC counts, the effect on CRP levels was less clear, highlighting areas for further investigation.
From a clinical perspective, the decision between MIS and open surgery should not be interpreted solely as a matter of surgical invasiveness, but rather as a patient- and pathology-specific strategy. Surgical intervention for pyogenic spondylodiscitis is generally indicated in cases of progressive neurological deficit, spinal instability or deformity, epidural or paravertebral abscess formation, failure of conservative treatment, sepsis, or medically intractable pain. Within this context, MIS approaches may be particularly suitable for selected patients with localized infection, limited instability, and substantial medical comorbidity, whereas open surgery remains relevant in cases requiring extensive debridement, deformity correction, anterior column reconstruction, or management of severe vertebral destruction.20
The significant reduction in postoperative pain scores observed with MIS approaches (standardized mean difference: −1.03) is a compelling finding, reinforcing the patient-centered benefits of these techniques. This aligns with the well-established principle that less tissue dissection translates to reduced nociceptive input and potentially faster functional recovery, as previously demonstrated in long case series studies on the treatment of spondylodiscitis.21–23 Similarly, the notably shorter length of hospital stay (MD: −3.96 days) and decreased wound revision rates (OR: 0.46) observed in the MIS group underscore the clinical efficiencies and reduced complication burden associated with these methods. These findings are consistent with previous meta-analyses and observational studies in other spinal conditions, where MIS has shown superior patient recovery profiles and lower rates of surgical site complications, often attributed to preservation of paraspinal musculature and reduced surgical trauma.11,24,25
Our results confirm that MIS approaches are associated with substantially lower intraoperative blood loss (MD: −321.27 mL) and shorter operative times (MD: −32.47 minutes) compared with open surgery, consistent with data reported in the literature, as evidenced by a recent systematic review that demonstrates the superiority of the minimally invasive procedure, showing a 40% reduction in intraoperative blood loss and a 3-fold lower complication rate (MIS 4% vs open 12%).26 The reduction in blood loss is a critical advantage, particularly in patients with pyogenic spondylodiscitis who may already be debilitated or anemic, potentially reducing the need for transfusions and their associated risks.27,28 The observed reduction in operative time, while potentially reflecting increased surgical efficiency or specialized workflows, carries significant clinical advantages for the patient. A shorter surgical duration translates to reduced anesthesia exposure, which can mitigate the risks of anesthesia-related complications and facilitate a faster emergence.29 Furthermore, decreased operative time is associated with lower physiological stress on the patient, all contributing to an improved safety profile and potentially a quicker postoperative recovery.30 However, the high heterogeneity observed in both blood loss (I² = 78%) and operative time (I² = 84%) warrants cautious interpretation, possibly reflecting differences in surgical techniques employed (eg, endoscopic debridement and percutaneous fixation), surgeon experience, and institutional protocols, as well as variability in reporting standards across studies.
The learning curve associated with MIS should also be considered when interpreting these findings. Endoscopic and other limited-access techniques require specific training, familiarity with indirect visualization, and experience with constrained working corridors. Differences in surgeon expertise may influence operative time, complication rates, completeness of debridement, and the threshold for conversion or staged procedures. Because most included studies did not report surgeon experience or institutional case volume, the impact of the learning curve could not be formally assessed in this meta-analysis.
The finding of significantly lower postoperative WBC counts in the MIS group (MD: −0.75, I² = 0%) is also a common finding in the literature, consistently reproduced in case series, multicenter studies, and reviews,31–33 both in cases of spondylodiscitis and in other spinal pathologies,34–36 and provides objective biological evidence supporting the concept of reduced systemic inflammatory response following less invasive procedures. This is a crucial physiological correlate to the observed clinical benefits, suggesting a more contained inflammatory cascade. In contrast, while a trend toward lower CRP levels was noted in the MIS group, this difference did not reach statistical significance (P = 0.56) and was accompanied by high heterogeneity (I² = 80%). The lack of statistical significance for CRP, despite a numerical reduction, may be due to several factors, including the inherent variability of CRP kinetics, timing of measurements, baseline inflammatory status of patients, or insufficient power of included studies to detect subtle differences in a highly variable biomarker. Future studies should standardize the timing of biomarker collection and explore other inflammatory markers to better elucidate the nuanced inflammatory response.
A notable challenge encountered in this meta-analysis was the significant heterogeneity observed across several key outcomes, particularly postoperative pain, intraoperative blood loss, and operative time, as well as CRP levels. A key limitation of the current literature is the significant heterogeneity within the category of MIS itself. MIS encompasses a spectrum of techniques with distinct surgical corridors, visualization methods, and biomechanical implications. As a result, pooling these techniques may obscure technique-specific advantages or limitations. This heterogeneity likely stems from a multitude of factors, including the inherent variability in surgical techniques classified under “MIS” (eg, differing approaches for debridement and stabilization), variations in patient selection criteria, discrepancies in outcome measurement (eg, nonstandardized assessment of intraoperative blood loss), and the predominant inclusion of observational studies, which are prone to confounding and diverse methodological rigor. While random-effects models were employed to account for this variability, the presence of substantial heterogeneity underscores the need for more standardized reporting and larger, prospective studies to provide more robust evidence.
Regarding adjunctive local antibiotic delivery, only 1 of the 11 included studies described the placement of indwelling catheters for postoperative antibiotic infiltration, consisting of continuous lavage of the intervertebral space with gentamicin-containing saline for up to 1 week in both the minimally invasive and the open groups, whereas a second study left negative-pressure drainage catheters within the debrided disc space using saline alone; in the remaining 9 studies, infection control relied exclusively on systemic antibiotic therapy. None of the studies reported catheter dwell time, irrigation composition, or removal criteria in a manner that would allow these variables to be extracted and analyzed. Because prolonged local antibiotic delivery may independently influence pain, infection control, and the normalization of inflammatory markers, this variability in adjunctive protocols constitutes an additional unmeasured source of heterogeneity that should be prospectively documented in future comparative studies.
Our meta-analysis is subject to several limitations that warrant consideration. First, the absence of RCTs represents a major limitation of the current evidence base. Observational studies are inherently subject to selection bias, as patients selected for MIS may differ systematically from those undergoing open surgery in terms of disease severity, comorbidities, and surgical indications. Therefore, the observed benefits of MIS should be interpreted with caution. Second, the high methodological heterogeneity across included studies, particularly concerning specific MIS techniques and outcome measurement, limited our ability to perform meaningful subgroup analyses for more granular comparisons. Finally, a large proportion of the studies did not provide details on follow-up duration, symptom recurrence, the need for additional debridement, or revision arthrodesis, which makes the long-term effectiveness of both procedures debatable.
Despite these limitations, the present findings may help refine surgical decision-making. MIS should be viewed as a valuable option within a broader treatment algorithm rather than as a universal replacement for open surgery. Its potential advantages appear most relevant in patients in whom infection control and stabilization can be achieved without extensive exposure. Conversely, open surgery continues to play an important role when wide decompression, radical debridement, correction of deformity, or anterior column reconstruction is required.
Future research should prioritize the conduct of well-designed RCTs to definitively compare MIS and open surgery for pyogenic spondylodiscitis, addressing the limitations of observational data. These trials should focus on standardizing surgical techniques, patient selection criteria, and outcome measurements, particularly for inflammatory markers (eg, serial CRP and WBC measurements at defined postoperative intervals) and long-term functional and quality of life outcomes. Investigation into specific patient subgroups, such as elderly or immunocompromised patients, would also be beneficial to determine the generalizability of MIS benefits. Furthermore, cost-effectiveness analyses are warranted to provide a comprehensive economic perspective on these surgical approaches.
Conclusion
This meta-analysis suggests that MIS for pyogenic spondylodiscitis offers significant short-term advantages in terms of reduced pain, shorter hospitalization, fewer wound complications, and more favorable intraoperative profiles compared with open surgery. These findings underscore the evolving landscape of spine surgery toward less invasive techniques for challenging conditions and provide valuable data to inform clinical practice, despite the inherent limitations of current observational evidence.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests All authors report no relationships that could be construed as a conflict of interest. All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Patient consent for publication ChatGPT-4 was used for rephrasing and clarification. The authors take full responsibility for the content of the manuscript.
Ethical Compliance The authors did not receive support from any organization for the submitted work. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this manuscript. This article does not contain any studies with human participants or animals performed by any of the authors.
Data Availability Statement All data used are present in the manuscript.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2026 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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