J Neurol Surg A Cent Eur Neurosurg 2013; 74(02): 087-095
DOI: 10.1055/s-0032-1320022
Original Article
Georg Thieme Verlag KG Stuttgart · New York

A Staged Treatment Algorithm for Spinal Infections

Carsten Stüer
1   Department of Neurosurgery, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
2   Department of Neurosurgery, Rheinische-Friedrich-Wilhelms University Bonn, Bonn, Germany
Michael Stoffel
1   Department of Neurosurgery, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
2   Department of Neurosurgery, Rheinische-Friedrich-Wilhelms University Bonn, Bonn, Germany
Judith Hecker
2   Department of Neurosurgery, Rheinische-Friedrich-Wilhelms University Bonn, Bonn, Germany
Florian Ringel
1   Department of Neurosurgery, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
2   Department of Neurosurgery, Rheinische-Friedrich-Wilhelms University Bonn, Bonn, Germany
Bernhard Meyer
1   Department of Neurosurgery, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
2   Department of Neurosurgery, Rheinische-Friedrich-Wilhelms University Bonn, Bonn, Germany
› Author Affiliations
Further Information

Publication History

13 June 2011

15 February 2012

Publication Date:
12 February 2013 (online)


Background and Study Aim Spinal pyogenic infections occur frequently in today's neurosurgical routine. Conservative therapy often proves to be insufficient against an aggressive disease that affects patients who tend to be elderly and debilitated with complex comorbidity. Treatment, or lack of treatment, carries risks of persistent disability, sepsis, and death. In this study, we propose a tailored and staged algorithm for treating such spinal infections and present results of this approach.

Patients and Methods We retrospectively analyzed 52 patients (33 male, 19 female; median age: 68 years) who had undergone cervical, thoracic, or lumbar surgery for spinal infections according to the proposed staged treatment algorithm.

Results Most of the 52 patients were severely disabled (35% with quadri- or paraparesis, 31% with sepsis and catecholamine dependency, 17% with a single motor deficit, and 10% with meningitis). We surgically treated multilevel and multisegmental spinal infections via 23 nonstabilizing and 57 stabilizing ventral or dorsal approaches to the cervical, thoracic, or lumbar spine. The mean follow-up time was 24 months. Overall mortality was 19%. Surgery-related complications occurred in 11.5% of patients; recurrence of infection occurred in 3.8%. Motor function improved in 61.7%; bladder and sphincter dysfunction remitted completely in 50.0%.

Conclusions Depending on the patient's health status and neurological condition, surgery in complex spinal infections provides a good outcome in most cases. Nevertheless, indication must be individualized; for this, the proposed algorithm seems to be an excellent tool. We find that surgery should be discussed as a treatment of first choice for today's often complex spinal infections.

  • References

  • 1 Digby JM, Kersley JB. Pyogenic non-tuberculous spinal infection: an analysis of thirty cases. J Bone Joint Surg Br 1979; 61 (1) 47-55
  • 2 Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother 2010; 65 (Suppl. 03) iii11-iii24
  • 3 Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine 2000; 25 (13) 1668-1679
  • 4 Jensen AG, Espersen F, Skinhøj P, Frimodt-Møller N. Bacteremic Staphylococcus aureus spondylitis. Arch Intern Med 1998; 158 (5) 509-517
  • 5 German Federal Bureau of Statistics. Public Health Service. 2005 ; Series 12: 1-79
  • 6 Weinstein MA, McCabe JP, Cammisa Jr FP. Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord 2000; 13 (5) 422-426
  • 7 Quiñones-Hinojosa A, Jun P, Jacobs R, Rosenberg WS, Weinstein PR. General principles in the medical and surgical management of spinal infections: a multidisciplinary approach. Neurosurg Focus 2004; 17 (6) E1
  • 8 Calderone RR, Larsen JM. Overview and classification of spinal infections. Orthop Clin North Am 1996; 27 (1) 1-8
  • 9 Akbar M, Lehner B, Doustdar S , et al. [Pyogenic spondylodiscitis of the thoracic and lumbar spine: a new classification and guide for surgical decision-making]. Orthopade 2011; 40 (7) 614-623
  • 10 Rath SA, Neff U, Schneider O, Richter HP. Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults: a review of 43 consecutive surgically treated patients. Neurosurgery 1996; 38 (5) 926-933
  • 11 Suess O, Weise L, Brock M, Kombos T. Debridement and spinal instrumentation as a single-stage procedure in bacterial spondylitis/spondylodiscitis. Zentralbl Neurochir 2007; 68 (3) 123-132
  • 12 Woertgen C, Rothoerl RD, Englert C, Neumann C. Pyogenic spinal infections and outcome according to the 36-item short form health survey. J Neurosurg Spine 2006; 4 (6) 441-446
  • 13 Przybylski GJ, Sharan AD. Single-stage autogenous bone grafting and internal fixation in the surgical management of pyogenic discitis and vertebral osteomyelitis. J Neurosurg 2001; 94 (1, Suppl) 1-7
  • 14 Wang Z, Lenehan B, Itshayek E , et al. Primary pyogenic infection of the spine in intravenous drug users: a prospective observational study. Spine 2012; 37 (8) 685-692
  • 15 Roques F, Nashef SA, Michel P , et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 1999; 15 (6) 816-822, discussion 822–823
  • 16 Frankel HL, Hancock DO, Hyslop G , et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969; 7 (3) 179-192
  • 17 Mann S, Schütze M, Sola S, Piek J. Nonspecific pyogenic spondylodiscitis: clinical manifestations, surgical treatment, and outcome in 24 patients. Neurosurg Focus 2004; 17 (6) E3
  • 18 Chan CT, Gold WL. Intramedullary abscess of the spinal cord in the antibiotic era: clinical features, microbial etiologies, trends in pathogenesis, and outcomes. Clin Infect Dis 1998; 27 (3) 619-626
  • 19 Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23 (4) 175-204 , discussion 205
  • 20 Ogden AT, Kaiser MG. Single-stage debridement and instrumentation for pyogenic spinal infections. Neurosurg Focus 2004; 17 (6) E5
  • 21 Lee MC, Wang MY, Fessler RG, Liauw J, Kim DH. Instrumentation in patients with spinal infection. Neurosurg Focus 2004; 17 (6) E7
  • 22 Schinkel C, Gottwald M, Andress HJ. Surgical treatment of spondylodiscitis. Surg Infect (Larchmt) 2003; 4 (4) 387-391
  • 23 Lerner T, Hackenberg L, Rösler S, Joosten U, Halm H, Liljenqvist U. [Surgical therapy of unspecific and specific Spondylodiscitis]. Z Orthop Ihre Grenzgeb 2005; 143 (2) 204-212
  • 24 O'Daly BJ, Morris SF, O'Rourke SK. Long-term functional outcome in pyogenic spinal infection. Spine 2008; 33 (8) E246-E253
  • 25 Löhr M, Reithmeier T, Ernestus RI, Ebel H, Klug N. Spinal epidural abscess: prognostic factors and comparison of different surgical treatment strategies. Acta Neurochir (Wien) 2005; 147 (2) 159-166 , discussion 166
  • 26 Martin RJ, Yuan HA. Neurosurgical care of spinal epidural, subdural, and intramedullary abscesses and arachnoiditis. Orthop Clin North Am 1996; 27 (1) 125-136
  • 27 Carragee EJ. Instrumentation of the infected and unstable spine: a review of 17 cases from the thoracic and lumbar spine with pyogenic infections. J Spinal Disord 1997; 10 (4) 317-324
  • 28 Isenberg J, Jubel A, Hahn U , et al. [Multistep spondylosyndesis-surgical management of progressive spondylodiscitis in patients with critical physical status]. Orthopade 2005; 34: 159-166
  • 29 Barnes B, Alexander JT, Branch Jr CL. Cervical osteomyelitis: a brief review. Neurosurg Focus 2004; 17 (6) E11
  • 30 Eismont FJ, Bohlman HH, Soni PL, Goldberg VM, Freehafer AA. Pyogenic and fungal vertebral osteomyelitis with paralysis. J Bone Joint Surg Am 1983; 65 (1) 19-29
  • 31 Niedhart C, Miltner O, Zilkens KW, Niethard FU. [Bacterial osteitis. Special considerations in immunocompromised patients]. Orthopade 2004; 33 (3) 297-304
  • 32 Fayazi AH, Ludwig SC, Dabbah M, Bryan Butler R, Gelb DE. Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis. Spine J 2004; 4 (4) 388-395
  • 33 Hempelmann RG, Mater E, Schön R. Septic hematogenous lumbar spondylodiscitis in elderly patients with multiple risk factors: efficacy of posterior stabilization and interbody fusion with iliac crest bone graft. Eur Spine J 2010; 19 (10) 1720-1727
  • 34 Deininger MH, Unfried MI, Vougioukas VI, Hubbe U. Minimally invasive dorsal percutaneous spondylodesis for the treatment of adult pyogenic spondylodiscitis. Acta Neurochir (Wien) 2009; 151 (11) 1451-1457
  • 35 Ringel F, Stoffel M, Stüer C , et al. Endoscopy-assisted approaches for anterior column reconstruction after pedicle screw fixation of acute traumatic thoracic and lumbar fractures. Neurosurgery 2008; 62 (5) (Suppl. 02) ONS445-ONS452
  • 36 Jeanneret B, Magerl F. Treatment of osteomyelitis of the spine using percutaneous suction/irrigation and percutaneous external spinal fixation. J Spinal Disord 1994; 7 (3) 185-205