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Objective: To describe for intervertebral spondylodiscitis (IS) its clinical characteristics, treatment approaches with intravenous (IV) antibiotics, and clinical implications of changes in treatment approach., Study Design: This retrospective study included all children aged 0-18 years diagnosed with imaging-confirmed thoracic and lumbar IS from 2000 to 2022 at a tertiary pediatric hospital. Patients with longer IV treatment regimen were compared with those with a shorter clinically directed IV to oral regimen., Results: In all, 124 cases were included with median age 14.9 months (IQR, 12.7-19.4 months) at diagnosis. Irritability and pain while changing diapers were common symptoms (52.4% and 49.2%, respectively). Elevated erythrocyte sedimentation rate (ESR) was the most common laboratory finding (95%; median, 50 mm/h [IQR 34-64 mm/h]). Elevated erythrocyte sedimentation rate was found in higher proportions (95%) compared with elevated C-reactive protein (76%; median, 1.8 mg/dL; P < .001). Since implementing the shorter clinically directed IV treatment duration for patients with thoracic and lumbar IS, hospitalization duration was decreased from a median of 12 to 8 days (P = .008) and IV treatment duration by a median of 14 to 8 days (P < .001). Only 1 patient (1.6%) in the clinically directed treatment group required rehospitalization owing to failure of therapy. Conversely, 9 of 124 children in the cohort suffered from IV treatment-related complications; all had been treated IV for prolonged periods., Conclusions: Early transition to oral treatment in pediatric spondylodiscitis seems to be appropriate clinically and shortens hospital stay and IV treatment duration without major negative clinical impact., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: The authors have no funding or conflicts of interest to disclose.

The ESC diagnostic criteria for infective endocarditis (IE) added spondylodiscitis as a minor criterion. This resulted in that 11 of 1807 patients with Staphylococcus aureus, streptococcal, or Enterococcus faecalis bacteremia, were reclassified from possible to definite IE, of whom only two were treated as IE., Competing Interests: Potential conflicts of interest. The authors: No reported conflicts of interest. The authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Ethical approval statement. The appropriate ethics approvals were accounted for in the original publications [6–8]., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objective: Pediatric spondylodiscitis (PSD) is an uncommon condition, for which there are no specific international clinical guidelines. Factors related to complications have not been stablished. Our aim was to describe clinical and epidemiological characteristics of PSD, to analyze factors associated with complications and to evaluate adherence to the recommendations of the Spanish National Consensus Document (NCD) for the diagnostic and therapeutic approach to acute osteoarticular infections., Material and Methods: Ambispective, multicenter, national study of two PSD cohorts: historical (2008-2012) and prospective (2015-2020, after publication of NCD). Patients with diagnosis of PSD were included. Demographic, clinical, microbiological and radiological data were recorded. Factors related to the development of complications were analized by logistic regression. Comparisons between both cohorts were performed., Results: Ninety-eight PSD were included. In 84.7%, diagnosis was confirmed by magnetic resonance imaging. Microbiological isolation was obtained in 6.1%, with methicillin-sensitive S. aureus as the main etiologic agent. Complications occurred in 18.9%, the most frequent being soft tissue abscess. Of the 8.6% of patients with sequelae, persistent pain was the most common. Comparing cohorts, there was better adherence to NCD treatment recommendations in the prospective one (57.6% vs. 12.9%, p < 0.01), including a reduction in the length of intravenous antibiotic therapy (10 vs. 14 days, p < 0.01)., Conclusions: The evolution of PSD in our series was favorable, with low frequency of complications and sequelae. The adherence to the recommendations of the NCD was high. Studies with larger sample size are needed to establish new recommendations to optimize the approach to these infections., (Copyright © 2024 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

Rationale: Pyogenic spondylodiscitis is an infectious spinal disease that causes significant motor dysfunctions. Its diagnosis can be challenging owing to its rapid onset and nonspecific symptoms., Patient Concerns: A 79-year-old Japanese man with a history of type 2 diabetes mellitus and polymyalgia rheumatica presented to our department with tongue pain. Following partial glossectomy and wisdom tooth extraction under general anesthesia, on 10 postoperative day (POD) the patient developed right-sided abdominal pain and difficulty in walking. On 12 POD, the patient was admitted to a municipal hospital due to respiratory distress and paraplegia., Diagnoses: The patient was diagnosed with pyogenic spondylodiscitis and empyema. Blood tests revealed elevated C-reactive protein levels (36.5), white blood cell count (19,570), and neutrophil count (17,867)., Interventions: The patient received meropenem hydrate 3 g/2 days as empiric antibiotic treatment for acute infection. Upon admission to the emergency department on 16 POD, the lung abscess was drained, hemilaminectomy was performed., Outcomes: Blood cultures, sputum tests, and cultures from the thoracic and spinal abscesses drained during surgery revealed methicillin-sensitive Staphylococcus aureus. The infection was successfully managed, and the respiratory disturbance and inflammatory response improved. However, the lower half of the patient body remained paralyzed. Subsequently, the patient was transferred to a rehabilitation facility on 45 POD. The patient continued to undergo functional restoration training, gradually regained function, and eventually achieved the ability to walk with grasping gait., Lessons: This is the first case report of S aureus causing pyogenic spondylodiscitis and empyema due to blood stream infection from a post-oral surgical wound. Pyogenic spondylodiscitis arising from a secondary hematogenous infection is difficult to diagnose and can lead to severe functional impairment. Prompt and appropriate diagnosis and treatment based on detailed patient interviews, additional blood tests, and computed tomography are essential., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objectives : Differentiation between brucella spondylodiscitis and Modic type I changes (MC1) includes difficulties. Hematological inflammatory indices (HII) such as neutrophil to lymphocyte ratio (NLR) and aggregate index of systemic inflammation (AISI) are suggested as indicators of inflammation and infection and have diagnostic, prognostic, and predictive roles in various diseases. This study aimed to evaluate differences between brucella spondylodiscitis and MC1 in terms of HII. Materials and Methods : Thirty-five patients with brucella spondylodiscitis and thirty-seven with MC1 were enrolled in the study. Brucella spondylodiscitis and MC1 were diagnosed by microbiological, serological, and radiological diagnostic tools. HII (NLR, MLR, PLR, NLPR, SII, SIRI, AISI) were derived from baseline complete blood count. Results : The two groups were similar for age ( p = 0.579) and gender ( p = 0.092), leukocyte ( p = 0.127), neutrophil ( p = 0.366), lymphocyte ( p = 0.090), and monocyte ( p = 0.756) scores. The Brucella spondylodiscitis group had significantly lower pain duration ( p < 0.001), higher CRP and ESR levels ( p < 0.001), and lower platelet count ( p = 0.047) than the MC1 group. The two groups had similarity in terms of HII: NLR ( p = 0.553), MLR ( p = 0.294), PLR ( p = 0.772), NLPR ( p = 0.115), SII ( p = 0.798), SIRI ( p = 0.447), and AISI ( p = 0.248). Conclusions : Increased HII can be used to differentiate infectious and non-infectious conditions, but this may be invalid in brucellosis. However, pain duration, CRP and ESR levels, and platelet count may be useful to distinguish brucella spondylodiscitis from MC1.

Nocturnal crying in toddlers has a broad spectrum of causes, including psychosocial and somatic causes, whereby the majority are self-limiting and do not need referral to specialist medical care. Although uncommon, atypical presentations of nocturnal crying-such as spondylodiscitis-require referral to specialist medical care, especially when combined with discomfort. In this case report, we present a case of a 15-month-old girl with an atypical presentation of nocturnal crying in combination with back pain., Competing Interests: Conflicts of interest None to report. The authors would like to thank the patients’ parents for providing their consent for this case report. The authors would also like to thank M. Reijnierse, A.J. van der Molen, V. Fejzovic, B. Boekestijn, D.A.W. Eijspaart, Y. Tank, J.L. Bloem (Department of Radiology, Leiden University Medical Centre) and L.F. de Geus-Oei (Department of Nuclear Medicine, Leiden University Medical Centre) for their radiological assessments., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Spinal infections are a diverse group of diseases affecting different compartments of the spine with variable clinical and imaging presentations. Diagnosis of spinal infections is based on a combination of clinical features, laboratory markers, and imaging studies. Imaging plays a pivotal role in the diagnosis and management of spinal infections. The characteristic imaging manifestations of bacterial and viral infections in the spine are discussed with key teaching points emphasized., Competing Interests: Disclosure P. Wangaryattawanich and T.J. Rath have no conflicts of interest to disclose, and there were no financial incentives that would alter the contents of this article. A.M. Condos: The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors are military service members. This study was prepared as part of official duties. Title 17 U.S C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” The authors received no financial compensation for this presentation. Neither I nor my immediate family members have a financial relationship with a commercial organization that may have a direct or indirect interest in the content., (Copyright © 2023 Elsevier Inc. All rights reserved.)

BACKGROUND Infantile spondylodiscitis is a rare condition with a varied clinical presentation. Microbial infection may not always be identified, but early diagnosis and management are required to prevent long-term and irreversible complications, including spinal deformities and vertebral instability. CASE REPORT This report is of a 21-month-old girl with a 3-week history of difficulty in walking and constipation due to L1-L2 spondylodiscitis following a gluteal skin burn. The family had sought medical advice multiple times, but results of all investigations were unremarkable. Her initial spine X-ray was negative but her spine magnetic resonance imaging (MRI) showed a picture suggestive of spondylodiscitis, which then responded to empiric treatment with broad-spectrum antibiotics. The patient showed complete resolution of clinical symptoms and her bowel habits came back to normal after 6 months of complete antibiotics treatment. Her repeat spine MRI showed a significant improvement of her spondylodiscitis. CONCLUSIONS This report has highlighted the importance of rapid diagnosis and management of infantile spondylodiscitis and the challenging approach to treatment when no infectious organism can be identified, as well as the early initiation of antibiotics therapy when appropriate in pediatric patients to avoid serious neurological complications associated with spondylodiscitis. Thus, it is essential to assess children with refusal to walk, gait problems, or back discomfort, especially when they are associated with high inflammatory markers.

Native vertebral osteomyelitis, also termed spondylodiscitis, is an antibiotic-resistant disease that requires long-term treatment. Without proper treatment, NVO can lead to severe nerve damage or even death. Therefore, it is important to accurately diagnose the cause of NVO, especially in spontaneous cases. Infectious NVO is characterized by the involvement of 2 adjacent vertebrae and intervertebral discs, and common infectious agents include Staphylococcus aureus, Mycobacterium tuberculosis, Brucella abortus, and fungi. Clinical symptoms are generally nonspecific, and early diagnosis and appropriate treatment can prevent irreversible sequelae. Advances in pathologic histologic imaging have led physicians to look more forward to being able to differentiate between tuberculous and septic spinal discitis. Therefore, research in identifying and differentiating the imaging features of these 4 common NVOs is essential. Due to the diagnostic difficulties, clinical and radiologic diagnosis is the mainstay of provisional diagnosis. With the advent of the big data era and the emergence of convolutional neural network algorithms for deep learning, the application of artificial intelligence (AI) technology in orthopedic imaging diagnosis has gradually increased. AI can assist physicians in imaging review, effectively reduce the workload of physicians, and improve diagnostic accuracy. Therefore, it is necessary to present the latest clinical research on NVO and the outlook for future AI applications.

Background : The incidence of pyogenic spondylodiscitis has been increasing in countries of Europe and North America, probably due to an increasing number of persons with risk factors for this infection. It is unclear whether HIV infection in the era of antiretroviral therapy (ART) increases the risk for spondylodiscitis. Method : We present 7 cases of pyogenic spondylodiscitis of the cervical, thoracic, and lumbar spine in six individuals living with HIV under ART with suppressed viral load. Results : All patients presented with severe non-radicular pain and elevated inflammatory markers. Diagnosis was confirmed by magnetic resonance imaging (MRI) scan and isolation of the pathogen. Staphylococcus aureus was the causative pathogen in five patients. One patient suffered from an infection with Klebsiella pneumoniae followed by a mixed infection with Cutibacterium acnes and Bacillus circulans 18 months later. All patients needed surgical intervention, and the mean duration of antibiotic treatment was 17 weeks (range 12-26). Five patients recovered fully, including two persons who also suffered from endocarditis. One patient died from multi-organ failure. Conclusion : Spondylodiscitis may be seen more frequently in persons living with HIV as they grow older and suffer from comorbidities which put them at risk for this infection. HIV physicians should be aware of the infection and its risk factors., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Non-specific features of spondylodiscitis lead to a delay and challenge in the diagnosis/differential diagnosis/treatment processes, and thus, serious complications may arise. This study aims to compare brucellar, pyogenic, and tuberculous types of spondylodiscitis, considering their demographic, clinical, and laboratory differences. This may provide more rapid management and good outcomes., Patients and Methods: A total of 131 patients with infectious spondylodiscitis were included in the study. The patients were divided into brucellar (n=63), pyogenic (n=53), and tuberculous (n=15) types of spondylodiscitis and compared for demographic, clinical, laboratory, and imaging features., Results: Tuberculous spondylodiscitis had higher scores for weight loss, painless palpation, thoracic spine involvement, and psoas abscess formation than other spondylodiscitis. Also, tuberculous spondylodiscitis had higher rates of neurologic deficit and lower rates of lumbar involvement than brucellar spondylodiscitis. Pyogenic spondylodiscitis is more likely to occur in patients who have a history of spine surgery compared to other forms of spondylodiscitis. Also, pyogenic spondylodiscitis had higher rates of fever, erythema, paraspinal abscess, white blood cell (WBC), and erythrocyte sedimentation rate (ESR) than brucellar spondylodiscitis. On the other hand, brucellar spondylodiscitis had higher rates of rural living and sweating than pyogenic spondylodiscitis., Conclusions: Weight loss, painless palpation, involved thoracic spine, psoas abscess, and neurologic deficit are symptoms favoring tuberculous spondylodiscitis. History of spine surgery, high fever, skin erythema, and paraspinal abscess are findings in favor of pyogenic spondylodiscitis. Rural living, sweating, and involved lumbar spine are symptoms that indicate brucellar spondylodiscitis. These symptoms can be used to distinguish the types of spondylodiscitis.

Background: Personalized clinical management of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) is challenging due to limited evidence of microbiologic findings and their clinical impact during the clinical course of the disease. We aimed to characterize clinico-microbiological and imaging phenotypes of SD and ISEE to provide useful insights that could improve outcomes and potentially modify guidelines., Methods: We performed chart review and collected data on the following parameters: bacterial antibiogram-resistogram, type of primary spinal infection, location of spinal infection, source of infection, method of detection, clinical complications (sepsis, septic embolism, and endocarditis), length of hospital and intensive care unit (ICU) stay, relapse rate, and disease-related mortality in patients with proven pyogenic SD and ISEE treated surgically in a university hospital in Germany between 2002 and 2022., Results: We included data from 187 patients (125 SD, 66.8% and 62 ISEE, 33.2%). Gram-positive bacteria (GPB) were overall more frequently detected than gram-negative bacteria (GNB) (GPB: 162, 86.6% vs. GNB: 25, 13.4%, p < 0.001). Infective endocarditis was caused only by GPB (GPB: 23, 16.5% vs. GNB: 0, 0.0%, p = 0.046). Methicillin-susceptible Staphylococcus aureus was the most frequently isolated strain (MSSA: n = 100, 53.5%), occurred more frequently in the cervical spine compared to other bacteria (OB) (MSSA: 41, 41.0% vs. OB: 18, 20.7%, p = 0.004) and was most frequently detected in patients with skin infection as the primary source of infection (MSSA: 26, 40.6% vs. OB: 11, 16.7%, p = 0.002). Streptococcus spp. and Enterococcus spp. (SE: n = 31, 16.6%) were more often regarded as the cause of endocarditis (SE: 8, 27.6% vs. OB: 15, 11.4%, p = 0.037) and were less frequently detected in intraoperative specimens (SE: 19, 61.3% vs. OB: 138, 88.5%, p < 0.001). Enterobacterales (E: n = 20, 10.7%) were identified more frequently in urinary tract infections (E: 9, 50.0% vs. OB: 4, 3.6%, p < 0.001). Coagulase-negative Staphylococci (CoNS: n = 20, 10.7%) were characterized by a lower prevalence of sepsis (CoNS: 4, 20.0% vs. OB: 90, 53.9%, p = 0.004) and were more frequently detected in intraoperative specimens (CoNS: 20, 100. 0% vs. OB: 137, 82.0%, p = 0.048). Moreover, CoNS-associated cases showed a shorter length of ICU stay (CoNS: 2 [1-18] days vs. OB: 6 [1-53] days, median [interquartile range], p = 0.037), and occurred more frequently due to foreign body-associated infections (CoNS: 8, 61.5% vs. OB: 15, 12.8%, p = 0.008). The presence of methicillin-resistant Staphylococcus aureus (MRSA) prolonged hospital stay by 56 [24-58] days and ICU stay by 16 [1-44] days, whereas patients with Pseudomonas aeruginosa spent only 20 [18-29] days in the hospital and no day in the ICU 0 [0-5] days., Conclusions: Our retrospective cohort study identified distinct bacterial-specific manifestations in pyogenic SD and ISEE regarding clinical course, neuroanatomic targets, method of pathogen detection, and sources of infection. The clinico-microbiological patterns varied depending on the specific pathogens., (© 2023. The Author(s).)

Background: Infection is one of the most common causes of death in hemodialysis patients. Catheter infections are among the most common infections in this patient group. Spondylodiscitis which has a high incidence in ESRD is more commonly encountered in patients with CVCs compared to AVF. In this study, we aimed to evaluate the frequency and risk factors of spondylodiscitis in catheter-related bloodstream infections in hemodialysis patients., Methods: In total, 1620 patients were screened and 42 male and 35 female patients with central catheter infection with a mean age of 65.8 ± 14.9 years were included in this study. Patients with metastatic infections secondary to CVC related bloodstream infections were determined. The diagnosis of spondylodiscitis was based on clinical information, computed tomography (CT) and magnetic resonance imaging (MRI), and vertebral cultures., Results: Metastatic infection due to catheter infection was observed in 15 patients (19.5%). In the regression analysis, CRP level and RRT time were found to be significantly correlated with the development of metastatic infection. Spondylodiscitis was the most common subtype of metastatic infections (8/15). The presence of lumbar hernia was associated with increased risk of metastatic spondylodiscitis in case of catheter infection in hemodialysis patients. The only factor associated with resistance to medical treatment was the time from admission to diagnosis., Conclusion: Patients with long RRT time and high blood CRP levels on admission should be closely monitored for metastatic infection in patients with CVC related bloodstream infections. Screening for spondylodiscitis with CT or MRI should be performed in patients with symptoms, since early diagnosis may prevent the development of possible neurological deficits and treatment resistance., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Objectives: Knowledge of Candida spondylodiscitis is limited to case reports and smaller case series. Controversy remains on the most effective diagnostical and therapeutical steps once Candida is suspected. This systematic review summarized all cases of Candida spondylodiscitis reported to date concerning baseline demographics, symptoms, treatment, and prognostic factors., Methods: A PRISMA-based search of PubMed, Web of Science, Embase, Scopus, and OVID Medline was performed from database inception to November 30, 2022. Reported cases of Candida spondylodiscitis were included regardless of Candida strain or spinal levels involved. Based on these criteria, 656 studies were analyzed and 72 included for analysis. Kaplan-Meier curves, Fisher's exact, and Wilcoxon's rank sum tests were performed., Results: In total, 89 patients (67% males) treated for Candida spondylodiscitis were included. Median age was 61 years, 23% were immunocompromised, and 15% IV drug users. Median length of antifungal treatment was six months, and fluconazole (68%) most commonly used. Thirteen percent underwent debridement, 34% discectomy with and 21% without additional instrumentation. Median follow-up was 12 months. The two year survivorship free of death was 80%. The two year survivorship free of revision was 94%. Younger age (p = 0.042) and longer length of antifungal treatment (p = 0.061) were predictive of survival., Conclusion: Most patients affected by Candida spondylodiscitis were males in their sixties, with one in four being immunocompromised. While one in five patients died within two years of diagnosis, younger age and prolonged antifungal treatment might play a protective role., (© 2023. The Author(s).)

The treatment of spinal infections is not well defined, and a cursory review of the literature can lead to conflicting treatment strategies. To add to the complexity, infections can include primary infection of the spine, infection secondary to another primary source, and postoperative infections including epidural abscesses, discitis, osteomyelitis, paraspinal soft-tissue infections, or any combination. Furthermore, differing opinions often exist within the medical and surgical communities regarding the outcomes and effectiveness of varying treatment strategies. Given the paucity of defined treatment protocols and long-term follow-up, it is important to develop multidisciplinary treatment teams and treatment strategies. This, along with defined protocols for the treatment of varying infections, can provide the data needed for improved treatment of spinal infections.

Background: Identification of the aetiologic agent in canine discospondylitis is infrequent; and risk factors for a positive bacterial culture have not previously been reported., Methods: Medical records at three institutions were searched to identify clinical features of dogs with discospondylitis diagnosed via radiography or cross-sectional imaging. Inclusion in this retrospective case-control study required culture of one or more samples. Multivariable binary logistic regression identified features associated with a positive culture., Results: Fifty (42%) of 120 dogs had one or more positive culture results obtained from either urine (28/115), blood (25/78), intervertebral disc aspiration (10/34) or cerebrospinal fluid (1/18). A positive culture was associated with higher bodyweight (p = 0.002, odds ratio [OR] = 1.054, 95% confidence interval [CI]: 1.019-1.089), more sample types cultured (p = 0.037, OR = 1.806, 95% CI: 1.037-3.147) and institution (p = 0.021). The presence of possibly associated preceding events (e.g., surgery), pyrexia, number of disc sites affected and serum C-reactive protein result, among other features, were not statistically significant., Limitations: All isolates cultured were included since differentiation of true aetiologic agents from contaminants was not possible without histological confirmation and culture from surgical or postmortem biopsies., Conclusions: Clinical features typically associated with infection were not identified as risk factors for positive culture in canine discospondylitis. The statistical significance of the institution suggests that standardisation of sampling protocols is necessary., (© 2023 British Veterinary Association.)

Background: Spondylodiscitis (SD), a rare disease in children, poses diagnostic challenges due to non-specific presenting symptoms, scarcity in incidence, and difficulty expressing pain in non-verbal children., Method: A comprehensive search was conducted on three databases, including PubMed/Medline, Web of Science, and Scopus until March 2023. The inclusion criteria were studies that investigated the clinical characteristics, treatment, and complications of children's spondylodiscitis. Full text of cross-sectional and cohort studies were added. The quality assessment of cohort studies was conducted using the Newcastle-Ottawa Quality Assessment Scale. The search, screening, and data extraction were performed by two researchers independently., Result: Clinical manifestations of discitis in children are nonspecific, such as back pain, fever, reduced ability or inability to walk or sit, limping, and reduced range of movements. The mean delay in the time of diagnosis was 4.8 weeks. The most affected site of all the studies was the lumbar spine. 94% of studies reported increased inflammatory markers such as white blood cell count, C-reactive protein, and erythrocyte sedimentation rate. Less than 30% of patients had positive blood cultures and biopsy findings. The most common microbiological results (64%) were Staphylococcus Aureus and Kingella kingae. In radiographic evaluation, intervertebral disk narrowing, lumbar lordosis reduction, loss of disk height, and destruction of the vertebral body have been reported. In all studies, antibiotic therapy was initiated; in 52% immobilization was employed, and 29% of studies reported surgery was performed, and the follow-up period differed from 1.5 months to 156 months. 94% of studies reported complications such as vertebral body destruction, back pain, kyphosis, reduced range of movement, scoliosis, and neurological complications., Conclusion: Spondylodiscitis is an uncommon, heterogeneous, multifactorial disease with resulting difficult and delayed diagnosis. Due to its morbidity, it is essential to investigate children with refusal to walk, gait disturbances, or back pain, particularly when associated with elevated inflammatory markers., (© 2023. The Author(s).)

Pyogenic spondylodiscitis presents significant diagnostic and therapeutic challenges. In Germany, a comprehensive understanding of its epidemiology and inpatient management outcomes is limited, hindering the optimisation of therapeutic strategies. This study aimed to characterise the evolving epidemiological trends of pyogenic spondylodiscitis in Germany, and concurrently evaluate inpatient management strategies and outcomes. We performed a retrospective population-based study of spondylodiscitis cases in Germany from 2005 to 2021, utilising data from the German Federal Statistical Office database. The parameters assessed were incidence trends, demographic characteristics, inpatient management strategies, and inpatient mortality. The study found a significant rise in the population-adjusted incidence of spondylodiscitis in Germany from 2005 to 2021, increasing by 104% from 5.4 to 11.0 cases per 100,000 individuals (p < 0.001). The highest number of diagnoses was recorded in 2019. Age group-adjusted data revealed the largest relative changes in the "90 + " age group, followed by the "80-89" and "70-79" age groups. These increases were not solely attributable to population changes but were also confirmed after calculating the age-group-adjusted incidence rates. Additionally, our statistical analysis demonstrated that both age and year significantly influenced the incidence of spondylodiscitis. Over the same period, inpatient mortality also surged significantly by 347% (p < 0.001), with the highest increase recorded in the 90 + age group, observing a 2450% rise (p < 0.001). The mean length of inpatient stay decreased by 15% (p < 0.05). Concurrently, there was a significant increase in surgical interventions using spinal stabilisation procedures (p < 0.001), which might suggest a shift in the treatment paradigm for spondylodiscitis. The results underscore a concerning rise in spondylodiscitis incidence and mortality in Germany, particularly affecting the ageing population. A notable shift towards surgical intervention was observed. The data highlights the urgent necessity for high-level evidence studies comparing surgical versus conservative treatment, thereby guiding optimised therapeutic strategies., (© 2023. The Author(s).)

Mycobacterium xenopi is a non-tuberculous mycobacterium (NTM) that sporadically causes infections in humans and can cause rare bone and joint infections in immunocompromised hosts with history of spinal surgery. This slow-growing mycobacterium takes 8-12 weeks to grow on culture. Metagenomic next-generation sequencing (MNGS) is a highly sensitive and specific plasma-based microbial cell-free DNA test that can detect M. xenopi weeks prior to culture growth. We present a case of M. xenopi lumbosacral discitis with presacral abscess in an immunocompromised woman without history of spinal surgery which was detected by MNGS 8 weeks prior to culture growth. The patient's discitis resolved with an M. xenopi -directed regimen of ethambutol, rifampin and azithromycin. This case illustrates the utility of next-generation sequencing tests in rapid diagnosis of rare and opportunistic infections, as compared with traditional diagnostic tests, with supporting contextual clinical and diagnostic findings., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Microbiological diagnosis of tuberculous spondylodiscitis (TS) and pyogenic spontaneous spondylodiscitis (PS) is sometime difficult. This study aimed to identify the predictive factors for differentiating TS from PS using clinical characteristics, radiologic findings, and biomarkers, and to develop scoring system by using predictive factors to stratify the probability of TS., Methods: A retrospective single-center study. Demographics, clinical characteristics, laboratory findings and radiographic findings of patients, confirmed causative pathogens of PS or TS, were assessed for independent factors that associated with TS. The coefficients and odds ratio (OR) of the final model were estimated and used to construct the scoring scheme to identify patients with TS., Results: There were 73 patients (51.8%) with TS and 68 patients (48.2%) with PS. TS was more frequently associated with younger age, history of tuberculous infection, longer duration of symptoms, no fever, thoracic spine involvement, ≥3 vertebrae involvement, presence of paraspinal abscess in magnetic-resonance-image (MRI), well-defined thin wall abscess, anterior subligamentous abscess, and lower biomarker levels included white blood cell (WBC) counts, erythrocyte-sedimentation-rate (ESR), neutrophil fraction, and C-reactive protein (all p < 0.05). Multivariate logistic regression analysis revealed significant predictors of TS included WBC ≤9,700/mm3 (odds ratio [OR] 13.11, 95% confidence interval [CI] 4.23-40.61), neutrophil fraction ≤78% (OR 4.93, 95% CI 1.59-15.30), ESR ≤92 mm/hr (OR 4.07, 95% CI 1.24-13.36) and presence of paraspinal abscess in MRI (OR 10.25, 95% CI 3.17-33.13), with an area under the curve of 0.921. The scoring system stratified the probability of TS into three categories: low, moderate, and high with a TS prevalence of 8.1%, 29.6%, and 82.2%, respectively., Conclusions: This prediction model incorporating WBC, neutrophil fraction counts, ESR and presence of paraspinal abscess accurately predicted the causative pathogens. The scoring scheme with combination of these biomarkers and radiologic features can be useful to differentiate TS from PS., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lertudomphonwanit et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Spondylodiscitis is a severe infectious disease of the spine that affects the intervertebral discs and adjacent vertebrae. It can lead to nonspecific pain, limited mobility, and destruction of spinal structures. Various pathogens, such as bacteria, fungi, or parasites, can trigger the disease. An early diagnosis and targeted treatment are crucial to reduce the risk of serious complications. Magnetic resonance imaging (MRI) with contrast agent and blood tests are essential for the diagnosis and assessing the course of the disease. The treatment includes conservative and surgical approaches. Conservative treatment consists of a minimum 6‑week antibiotic course and immobilization of the affected area. Surgical interventions, along with several weeks of antibiotic therapy, are indicated for instabilities or complications in order to eliminate the infection focus and to restore spinal stability., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Aspergillus spondylodiscitis is a rare entity reported in the literature. In tuberculosis endemic regions like India, more often it could be misdiagnosed as tuberculous spondylodiscitis. Herein we report a case series of three patients with Aspergillus spondylodiscitis presenting with chronic low backpain and clinically diagnosed as tuberculosis spine. Culture and histopathological examination of the debrided tissue provided a definite diagnosis. Interestingly, one of the cases had coexisting tuberculosis spine. All three patients underwent surgical intervention-debridement, decompression and fusion of spine and combined medical management with voriconazole with successful outcome., Competing Interests: Conflict of interest Nil., (Copyright © 2023 Indian Association of Medical Microbiologists. Published by Elsevier B.V. All rights reserved.)

In spondylodiscitis, pathogen identification is important to guide therapy strategies. Here the use of an rDNA PCR assay (Molzym UMDSelectNA) for pathogen detection in spondylodiscitis was evaluated in 182 specimens from 124 spondylodiscitis patients. In 81% of specimens rDNA PCR and conventional culture produced concordant results. Compared to conventional culture, sensitivity and specificity of rDNA PCR were 75% and 83.9%, respectively. The rDNA PCR performed better than conventional culture in identification of Streptococcus spp.. However, overall sensitivity was suboptimal, e.g., in cases with low bacterial burden, and only 5 of 124 patients (4%) received a microbiological diagnosis by employing rDNA PCR. Thus, the added value of routine use of rDNA PCR on spondylodiscitis specimens is limited. Targeted use of the assay in culture-negative cases may be efficient and moderately increase diagnostic yield. The need for susceptibility information implies that 16S rDNA PCR may only be used as an add-on tool to culture., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: The incidence of pyogenic spondylodiscitis is increasing, and the disease is associated with considerable morbidity, mortality, long-term healthcare utilization and societal costs. Disease-specific treatment guidelines are lacking and there is little consensus regarding optimal conservative and surgical management. This cross-sectional survey of German specialist spinal surgeons sought to determine practice patterns and degree of consensus regarding the management of lumbar pyogenic spondylodiscitis (LPS)., Methods: An electronic survey covering provider information, diagnostic approaches, treatment algorithms, and follow-up care of patients with LPS was distributed to members of the German Spine Society., Results: Seventy-nine survey responses were included in the analysis. Magnetic resonance imaging is the diagnostic imaging modality of choice for 87% of respondents; 100% routinely measure C-reactive protein in suspected LPS and 70% routinely take blood cultures before therapy initiation; 41% believe that surgical biopsy to obtain microbiological diagnosis should be carried out in all cases of suspected LPS, whereas 23% believe that surgical biopsy should only be carried out when empirical antibiotic therapy proves ineffective; 38% believe an intraspinal empyema should always be surgically evacuated, regardless of spinal cord compression. The median intravenous antibiotic duration is 2 weeks. The median total duration of the antibiotic therapy (intravenous and oral) is 8 weeks. Magnetic resonance imaging is the preferred imaging modality for follow-up of both conservatively and operatively treated LPS., Conclusions: There exists considerable variation of care in the diagnosis, management, and follow-up of LPS among German spine specialists with little agreement on key aspects of care. Further research is required to understand this variation in clinical practice and to enhance the evidence base in LPS., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to determine threshold values of validated quality of life (QoL) scores, including Oswestry Disability Index (ODI) and Core Outcome Measures Index (COMI), for predicting a successful outcome following surgical treatment of lumbar spondylodiscitis (LS)., Methods: Patients with lumbar spondylodiscitis (LS) undergoing surgery in a tertiary referral hospital were included prospectively from 2008-2019. Data were collected both before surgery (T0) and one year after surgery (T1). QoL was measured using ODI and COMI. The successful clinical outcome was defined by the combination of the following four criteria: no recurrence of spondylodiscitis, back pain ≤4 on visual analogue scale or relief of ≥3 points, absence of LS-related neurological deficit, and radiological fusion of the affected segment. For subgroup analysis, group 1 consisted of patients with a favorable treatment outcome (meeting all four criteria), while group 2 included patients with unfavorable treatment outcome (meeting ≤3 criteria)., Results: Ninety-two LS patients (median age = 66 years; age range = 57-74) were analyzed. QoL scores improved significantly. Threshold values for the ODI and COMI were calculated at 35 and 4.2 points, respectively. The area under curve for the ODI was 0.856 (95%-CI 0.767- 0.945; P<0.001) and 0.839 (95% CI-0.749-0.928; P<0.001) for the COMI score. Eighty percent of patients achieved a favorable outcome., Conclusion: Objective measurement and evaluation of successful surgical treatment of spondylodiscitis require defined thresholds of quality of life scores. We were able to define such thresholds for Oswestry Disability Index and Core Outcome Measures Index. These can be useful to assess clinically relevant changes and therefore allow a more precise estimation of the post-surgical outcome., Level of Evidence: Level II, Prognostic study.

Dysregulated systemic immune responses during infectious spondylodiscitis (IS) may impair microbial clearance and bone resorption. Therefore, the aim of the study was to examine whether circulating regulatory T cells (Tregs) are elevated during IS and whether their frequency is associated with alterations in T cells and the presence of markers of bone resorption in the blood. A total of 19 patients hospitalized with IS were enrolled in this prospective study. Blood specimens were obtained during hospitalization and 6 weeks and 3 months after discharge. Flow cytometric analysis of CD4 and CD8 T cell subsets, the percentage of Tregs and serum levels of collagen type I fragments (S-CrossLap) were performed. Out of 19 enrolled patients with IS, microbial etiology was confirmed in 15 (78.9%) patients. All patients were treated with antibiotics for a median of 42 days, and no therapy failure was observed. Next, a significant serum C-reactive protein (S-CRP) decrease during the follow-up was observed, whereas the frequencies of Tregs remained higher than those of controls at all-time points (p < 0.001). In addition, Tregs demonstrated a weak negative correlation with S-CRP and S-CrossLap levels were within the norm at all-time points. Circulating Tregs were elevated in patients with IS and this elevation persisted even after the completion of antibiotic therapy. Moreover, this elevation was not associated with treatment failure, altered T cells, or increased markers of bone resorption., Competing Interests: Declaration of Competing Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023. Published by Elsevier B.V.)

COVID-19 is currently a major health problem, leading to respiratory, cardiovascular and neurological complications, with additional morbidity and mortality. Spinal infections are rare, representing around 1% of all bone infections and comprising less than 2 per 10,000 of all hospitalizations in tertiary care centers. Spondylodiscitis is a complex disease, with challenging diagnosis and management. We report the case of a 45-year-old man, non-smoker hospitalized for severe COVID-19 disease with respiratory failure. Post-COVID-19, in the 8th week after discharge, he was diagnosed by magnetic resonance imaging with spondylodiscitis, but etiology was not confirmed by microbiological investigations. Antibiotics were used, considering the identification of MRSA from cultures of pleural fluid and nasal swab, but surgical intervention was not provided. Clinic, biologic and imagistic were improved, but rehabilitation and long term follow up are necessary. We concluded that spondylodiscitis with spinal abscess is a rare but severe complication post-COVID-19 disease, due to dysbalanced immune response related to the respiratory viral infection, endothelial lesions, hypercoagulation and bacterial superinfection.

Purpose: Discitis represents infection of the intervertebral disc and osteomyelitis of the adjacent end plates. Classically, patients present with fever and back pain. Varied presentations and lack of adherence to guidelines lead to great variation in its identification and management. The primary objective of this study was to conduct a cohort analysis, assessing the identification and management of discitis, in a busy secondary orthopaedic centre., Methods: A retrospective study was conducted, of cases diagnosed and treated for discitis, in a secondary orthopaedic department, within the UK from January 2017 to October 2019. During this time period, all patients who underwent magnetic resonance imaging (MRI) spine were identified. Patients with MRI-proven discitis were then added into the study., Results: A total of 152 MRIs showed radiographic features of discitis. Of these, only 38 had a clear clinical correlation. Back pain was the most common presenting complaint followed by fever. The commonest site of involvement was vertebral levels L5 and S1. All patients had baseline bloods, and most, but not all, had blood cultures taken. Staphylococcus aureus was the most frequently isolated, causative organism. The mainstay of treatment was intravenous flucloxacillin, with most patients requiring a minimum of six weeks., Conclusion: Our study has helped define the population of patients presenting with discitis, in a busy secondary orthopedic center. Analyzing over two years of data has provided us with valuable insight into the most appropriate diagnostics and management for discitis., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Disseminated nocardiosis is a very rare disease. By now only few cases of meningitis and spondylodiscitis have been reported. To our knowledge, this is the first case of meningitis caused by Nocardia nova., Case Presentation: We report on a case of bacteraemia, meningitis and spondylodiscitis caused by N. nova in an immunocompetent patient. We describe the long, difficult path to diagnosis, which took two months, including all diagnostic pitfalls. After nocardiosis was diagnosed, intravenous antibiotic therapy with ceftriaxone, later switched to imipenem/cilastatin and amikacin, led to rapid clinical improvement. Intravenous therapy was followed by oral consolidation with co-trimoxazole for 9 months without any relapse within 4 years., Conclusions: Establishing a diagnosis of nocardiosis is a precondition for successful antibiotic therapy. This requires close communication between clinicians and laboratory staff about the suspicion of nocardiosis, than leading to prolonged cultures and specific laboratory methods, e.g. identification by 16S rDNA PCR., (© 2023. The Author(s).)

Purpose: Biopsy of the spine can be performed by open surgery or percutaneous needle sampling. The first has the highest diagnostic yield while the second is a less invasive procedure with lower rate of complications and shorter hospitalization time. We described a modified technique of percutaneous biopsy using semi-rigid grasping forceps that may offer the advantages of both, open and minimally invasive surgery., Methods: Thirty consecutive patients with spinal lesions requiring biopsy were admitted to Neurosurgical Unit of Belcolle Hospital (Viterbo, Italy) from January 2017 to September 2021. There was a suspicion of spondylodiscitis in 25 cases and of tumor in 5 cases. Percutanous trans-pedicular spine biopsy has been performed using this new semi-rigid grasping forceps. Combining the opening width, jaw length and full 360° rotation, the device allows a wide and precise sampling., Results: Sampling was sufficient in all cases (100%); tumors was observed in 5 cases (16.7%%) with a percentage of definitive histopathologic diagnosis of 100% (n = 5); among the remaining patients histological examination yielded a diagnosis of spinal infection in 25 cases (100%), and microbiologic culture provided an aetiologic diagnosis in 23 cases (92%). All procedures were well tolerated, and no postoperative complications were observed. Levels involved included: thoracic (T5-T9) in 8 cases, thoracolumbar junction (T10-L2) in 12 cases and lumbar (L3-L5) in 10 cases., Conclusions: Percutaneous biopsy with the semi-rigid grasping forceps is a safe and effective procedure that can be used for diagnosis of both infectious and tumor lesions of the spine. It allows to obtain a larger specimen volume and to use a multidirectional trajectory for sampling, resulting in a minimally invasive technique with strong ability to yield etiologic diagnosis., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Despite advances, the morbidity and mortality rates of patients with spondylodiscitis remains high, with an increasing incidence worldwide. Although conservative therapy has progressed, several cases require surgical intervention. However, the indication and opportunities for surgical treatment are still disputable., Methods: In a joint consensus, the members of the 'Spondylodiscitis' working group of the Spine Section of the German Society for Orthopaedics and Trauma Surgery considered current literature, particularly the newly published S2k guideline of the AWMF, and examined the surgical indications and treatment strategies for thoracolumbar spondylodiscitis., Results: Surgical intervention for spondylodiscitis is only required in a small percentage of patients. In studies comparing conservative and surgical therapies, most patients benefitted from surgery, regardless of the surgical technique selected. Presently, the standard procedure is a combined dorsoventral approach, in which a monolateral attempt should always be made. The choice of material (PEEK, titanium) for ventral support does not influence the clinical result., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objective: Spinal infections, represent quite rare but often severe conditions. However, due to symptoms' non-specificity and the lack of specific laboratory tests, diagnosis is often delayed with serious consequences for the patient's outcomes. The present investigation aimed at evaluating the role of procalcitonin (PCT) and other clinical features on the risk stratification and the clinical outcomes in spondylodiscitis patients treated in our Emergency Department., Patients and Methods: The present investigation represents a single-center retrospective study. Clinical records of consecutive patients admitted to our Emergency Department from 1 January 2015 to 31 March 2021 were evaluated and patients with spondylodiscitis diagnosis in this period were recruited. Our primary outcome was the degree of autonomy of patients following the acute event. Our secondary outcome was the resolution of the infection., Results: In the study period, a total of 345 patients were evaluated. Among these, 165 met the inclusion criteria, and constituted the study cohort. Concerning the primary outcome, we observed that the most significant predictive factors for being non-autonomous were elevated serum creatinine (> 1.05 mg/dl), Blood Urea Nitrogen (BUN) > 23 mg/dl, Lactate dehydrogenase > 228 U/L, PCT > 0.11 ng/mL. Patients with higher PCT (PCT > 0.11 ng/mL) and higher BUN (BUN > 23 mg/dl) had higher odds of infection persistence (the Odd Ratio, OR, were respectively 3.78 for PCT and 3.14 for BUN)., Conclusions: PCT assay may play a role in diagnosing spondylodiscitis in an emergency setting. A PCT value > 0.11 ng/mL should be considered as a red flag, a predictor of worse clinical outcomes and persistence of infection.

Spondylodiscitis is often diagnosed late in its course because its symptoms are vague. The incidence in adults increases with age, being seen most commonly in men in their 50s and 60s, so the presence of other medical conditions or infections can make it more difficult to identify spondylodiscitis. Diagnosis is made based on clinical suspicion, raised levels of inflammatory markers, a positive blood or tissue biopsy culture and radiological findings. Once a diagnosis is confirmed, treatment must be started promptly. The mainstay of treatment is medical management, with antibiotics tailored to the relevant organism, as well as immobilisation. Where surgery is indicated, the aims are debridement of infected tissue, tissue sampling, neural decompression and stabilisation. Spondylodiscitis is associated with high rates of mortality and morbidity and should be treated promptly to ensure the best outcome.

Spontaneous spinal infections, such as pyogenic spondylodiscitis(PSD)and spinal epidural abscess(SEA), are relatively rare, but the number of patients is increasing because of the increase in the older population with chronic comorbidities. Magnetic resonance imaging is the most useful tool for identifying PSD or SEA, with high sensitivity and specificity. Effective antibiotic medication is essential to treat the infection, and selection of antibiotics should be based on not only sensitivity to the causative bacteria, but also ability to penetrate bone tissues. Medication should be continued for at least 6 weeks while monitoring C-reactive protein levels. Surgical treatment is indicated when neurological symptoms or severe spinal instability cannot be managed conservatively. Percutaneous endoscopic surgery enables simultaneous tissue sampling for diagnosis and curative debridement without injury to the spinal supporting tissues. Anterior debridement and interbody fusion(ADIF)with autologous bone grafts have been frequently used for PSD. ADIF can be applied more easily to the lumbar spine using techniques and devices for lateral interbody fusion. Posterior decompression is frequently performed in patients with SEA without severe spinal instability. Percutaneous posterior instrumentation, with or without posterior decompression, is a useful option for PSD, especially in the thoracic spine.

Introduction: Spondylodiscitis accompanying spinal epidural abscess is often treated with decompression surgery when there are neurological symptoms. We report a case of spondylodiscitis accompanying spinal epidural abscess with severe lower extremity pain that was successfully treated with percutaneous posterior pedicle screw fixation without decompression surgery., Case Presentation: A 53-year-old man was admitted to our hospital with severe low back pain (LBP), lower extremity pain and numbness, and fever. Lumbar magnetic resonance imaging (MRI) revealed spondylodiscitis at L2-L3 and a small epidural abscess located ventrally in the spinal canal. Initially, the patient was treated conservatively with empirical antibiotics. However, the lower extremity symptoms worsened and the epidural abscess expanded cranially to the T12 level. Percutaneous pedicle screw fixation without decompression was performed thirty-three days after admission. Postoperatively, the LBP and lower extremity pain dramatically improved. A postoperative MRI performed one week post-operatively showed an unexpectedly rapid decrease in the size of the epidural abscess, although no decompression surgery was performed. Two months after surgery, the epidural abscess completely disappeared. At the final follow-up (five years postoperatively), no recurrence of epidural abscess was observed, and the patient had no symptoms or disturbance of activities of daily living., Discussion: This surgical strategy should be carefully selected for patients with spondylodiscitis with accompanying spinal epidural abscess who have lower extremity symptoms. The stabilising effect of pedicle screw fixation may be advantageous for controlling spinal infections. Percutaneous posterior pedicle screw fixation without decompression is an optional treatment for spondylodiscitis accompanying spinal epidural abscess., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background: Pediatric spondylodiscitis is rare, hardly diagnosed and treated due to the nonspecificity of clinical presentation and laboratory investigations, difficulty of etiologic identification and lack of management guidelines., Methods: A retrospective study was conducted on 29 children with spondylodiscitis. Clinical, hematic and radiologic data were collected and compared between 2 age-subgroups (below and from 4 years old on) to investigate age-related differences. Epidemiologic, management and follow-up data were also described., Results: Slight male predominance and a peak of incidence <2 years were observed. Symptoms were significantly differently distributed in the 2 age-subgroups: children <4 years showed mainly refusal/inability to sit or bear weight, irritability, limping and poor general conditions; children ≥4 years most frequently had back pain and fever, and pain upon palpation of the spine. The lumbar spine and more than 1 vertebra were most frequently involved. Median diagnostic delay of 12 days was observed, without significant difference between age-subgroups, and delay >2 months was always associated with multivertebral involvement and complications. All children were treated with broad-spectrum antibiotics for a median of 12 weeks. Only in 1 complicated case, surgical treatment was also required., Conclusions: The clinical presentation of spondylodiscitis may be age-specific, with younger children often exhibiting subtle signs and symptoms. Broad-spectrum antibiotics covering for Staphylococcus aureus should be initiated as soon as possible and performed many weeks, being effective in treating the infection without clinical sequelae, even in patients with comorbidities. Surgical treatment should be reserved for complicated cases with neurologic involvement., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

BACKGROUND Pyogenic spondylitis comprises several clinical entities, including native vertebral osteomyelitis, septic discitis, pyogenic spondylodiscitis, and epidural abscess. The lumbar spine is most often infected, followed by the thoracic and cervical areas. It mainly develops (i) after spine surgery; (ii) from history of blunt trauma to the spinal column; (iii) from infections in adjacent structures (such as soft tissues); (iv) from iatrogenic inoculation after invasive procedures (such as lumbar puncture); and (v) from hematogenous bacterial spread to the vertebra (mainly through the venous route). Any delay in diagnosis and treatment can lead to significant spinal cord injury, permanent neurological damage, septicemia, and death. CASE REPORT We describe a 63-year-old man with no significant past medical history who presented with fever and an altered level of consciousness. Significant thoracic spine pain was also reported during the last 3 months. The final diagnosis was vertebral spondylodiscitis, contiguous spinal epidural abscess, and sepsis due to Bacteroides fragilis bacteremia. Clinical recovery was achieved after surgical decompressive therapy with abscess drainage combined with appropriate antibiotic therapy for 12 weeks. The primary focus of the infection was not clarified, despite all the investigations that were performed. CONCLUSIONS Spondylodiscitis, spinal epidural abscess, and sepsis as complications of Bacteroides fragilis bacteremia are rare in a patient without any previously known predisposing conditions and without an obvious primary focus. Early diagnosis and proper treatment of anaerobic spondylodiscitis, especially if epidural abscess and sepsis are present, are of great importance to reduce mortality and avoid long-term complications.

Purpose: In patients with pyogenic spondylodiscitis, surgery is considered the treatment of choice to conduct proper debridement, stabilise the spine and avoid extended bed rest, which in turn is a risk factor for complications such as deep vein thrombosis and pulmonary embolism., Methods: We conducted a retrospective clinical study with analysis of a group of 99 patients who had undergone treatment for pyogenic discitis at our institution between June 2012 and August 2017. Included parameters were age, sex, disease pattern, the presence of deep vein thrombosis, resuscitation, in-hospital mortality, present anticoagulation, preexisting comorbidities, tobacco abuse, body mass index, microbiological germ detection and laboratory results., Results: Among the analysed cohort, 12% of the treated patients for pyogenic spondylodiscitis suffered from a radiologically confirmed pulmonary embolism. Coronary heart disease (p < 0.01), female sex (p < 0.01), anticoagulation at admission (p < 0.01) and non-O blood type (p < 0.001) were associated with development of pulmonary embolism. Pulmonary embolism was significantly associated with resuscitation (p < 0.005) and deep vein thrombosis (p < 0.001). Neurosurgery was not associated with increased risk for pulmonary embolism compared to conservative-treated patients (p > 0.05)., Conclusion: Surgery for pyogenic spondylodiscitis was not associated with an elevated risk of pulmonary embolism in our analysis. However, we describe several risk factors for pulmonary embolism in this vulnerable cohort. Prospective studies are necessary to improve prevention and postoperative management in patients with pyogenic spondylodiscitis., (© 2021. The Author(s).)

Previously, the simultaneous presence of endocarditis (IE) has been reported in 3-30% of spondylodiscitis cases. The specific implications on therapy and outcome of a simultaneous presence of both diseases are not yet fully evaluated. Therefore, the aim of this study was to investigate the influence of a simultaneously present endocarditis on the course of therapy and outcome of spondylodiscitis. A prospective database analysis of 328 patients diagnosed with spontaneous spondylodiscitis (S) using statistical analysis with propensity score matching was conducted. Thirty-six patients (11.0%) were diagnosed with concurrent endocarditis (SIE) by means of transoesophageal echocardiography. In our cohort, the average age was 65.82 ± 4.12 years and 64.9% of patients were male. The incidence of prior cardiac or renal disease was significantly higher in the SIE group (coronary heart disease SIE n = 13/36 vs. S n = 57/292, p < 0.05 and chronic heart failure n = 11/36 vs. S n = 41/292, p < 0.05, chronic renal failure SIE n = 14/36 vs. S n = 55/292, p < 0.05). Complex interdisciplinary coordination and diagnostics lead to a significant delay in surgical intervention (S = 4.5 ± 4.5 days vs. SIE = 8.9 ± 9.5 days, p < 0.05). Mortality did not show statistically significant differences: S (13.4%) and SIE (19.1%). Time to diagnosis and treatment is a key to efficient treatment and patient safety. In order to counteract delayed therapy, we developed a novel therapy algorithm based on the analysis of treatment processes of the SIE group. We propose a clear therapy pathway to avoid frequently observed pitfalls and delays in diagnosis to improve patient care and outcome., (© 2021. The Author(s).)

Concomitant existence of spondylodiscitis and a psoas abscess in a patient with a history of plasmacytoma should be the subject of extensive etiological research., (Copyright © 2022 SFMTSI.)

Spinal epidural abscess (SEA) is a rare but severe infection with potentially devastating consequences. Epidural abscesses caused by Salmonella serogroup C2 are even rarer and tend to be more invasive with multidrug resistance. Early diagnosis, effective use of antibiotics and surgical intervention are the mainstay strategies for managing SEA, especially for more virulent and multidrug-resistant Salmonella infections. This case report presents a rare case of an elderly and fragile woman with Salmonella spondylodiscitis and an extensive epidural abscess, which were successfully treated with intravenous antibiotics and unilateral biportal endoscopic (UBE) debridement and drainage through four small surgical incisions. After surgery, her fever subsided, she regained consciousness and her low back pain dramatically improved. Follow-up magnetic resonance imaging showed complete resolution of the epidural abscess. At 6 months after surgery, the patient regained muscle strength, ambulated with a walker and had no recurrence of the infection. The UBE technique can effectively eradicate infection while minimizing surgery-related risks and complications. A multidisciplinary team is required to achieve a good outcome.

Purpose: The aim of the study was to investigate whether MRI findings together with epidemiological data could help in differentiating between tuberculous and pyogenic spondylodiscitis., Methods: Clinical records of 260 patients with a suspicion of spondylodiscitis were analysed. Patients were selected using the following inclusion criteria: confirmed diagnosis of spondylodiscitis either from pyogenic bacteria or from Mycobacterium tuberculosis and contrast-enhanced MRI performed before treatment. Clinical data concerning age, sex and country-of-origin were also collected. For each patient, several MRI-features were evaluated by two-expert musculoskeletal radiologists. A chi-squared test and a multiple logistic regression were used to find the best predictors of tuberculous or pyogenic spondylodiscitis., Results: 114 patients were retrospectively enrolled, 30 with tuberculous and 84 with pyogenic spondylodiscitis. We found 18 MRI-features, significantly different between the two groups. Among these, the most strongly associated with tuberculous spondylodiscitis were: heterogeneous vertebral signal on T1w-sequences (Odds Ratio(OR) = 205.759-p < 0.001), presence of epidural abscess (OR = 86.221-p < 0.001), severe vertebral destruction (OR = 10.017-p < 0.001) and absence of epidural phlegmon (OR = 86.221-p < 0.001). Moreover, patients coming from countries with a middle-high prevalence of tuberculosis were more frequently affected by tuberculous spondylodiscitis than others were (OR = 229.136-p < 0.001). The best prediction model demonstrated a correct classification rate of 94.7%., Conclusion: To the best of our knowledge this is the largest study comparing MRI-features of tuberculous and pyogenic spondylodiscitis. The above-mentioned MRI-features and epidemiological data are crucial in the differential diagnosis between these two entities, guiding the choice of the appropriate therapy, especially when a pathogen cannot be clearly identified with other modalities., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)