Chirurgische Behandlung und Outcome in einer konsekutiven Serie von 237 Patienten mit Spondylodiszitis

OBJECTIVE. Operative therapy of spondylodiscitis is increasingly evolving to the first line therapy in the clinical practice. In this study we describe our experience in the treatment of spondylodiscitis with current operative techniques as well as parameters which show importance for the outcome to validate the surgical trend and optimize therapy. METHODS. Retrospective review identified 237 patients who were operatively treated for spondylodiscitis at our institution in the period January 2010 - December 2018. RESULTS. We included 237 patients in the study, 87 females (36.7%) and 150 males (63.3%) with mean age 71.4 years. Mean follow up was 31.62 months. Average duration of hospital stay was 14.1 days (SD 16.3). Twenty-six patients died during the follow up (11%). 45 patients (19%) had spondylodiscitis of the cervical spine, 73 or 30,8 % of the thoracic spine and 119 or 50.2 % of the lumbosacral spine. 62 or 26.2% of patients had postoperative spondylodiscitis. 148 patients or 62.4% had isolated spondylodiscitis, 89 patients or 37.6 % had concomitant infections. All patients had increased laboratory infection parameters leukocyte count and CRP with mean preoperative CRP value of 160.8. 172 patients or 72.6% had neurological deficits. Pain was the most common symptom (94,9%). Ventral approach was performed in 45 or 21.1% of patients (exclusively cervical spine), 31 patients received a ventral discectomy and PEEK Cage implantation, 14 patients a corpectomy and vertebral body expandable cage implantation with plating. Additional dorsal stabilization was performed in 23 cases (360◦ Fusion). In 54 patients discectomy/ nucleotomy with evacuation of the empyema was performed without additional stabilization (all with dorsal approach and monosegmental spondylodiscitis in the thoracic or lumbar spine). The majority of patients (138 or 58,2%) received treatment by dorsal instrumentation, all of them were affected in thoracic or lumbar spine. Additional PEEK-cages were implanted in 45 (from this number 22 in lateral approach), additional titan-cages in 35 of those cases. Complete healing occurred in 91.5% of patients. Mean time of cumulative application of antibiotic therapy was 73.9 days. Neurological status improved in 101 patients (42.6%), remained unchanged in 95 (40%) and worsened in 15 patients (6.3%). Patients with isolated spondylodiscitis, id est without concomitant infections (n = 148), had significantly favourable outcome compared to patients with concomitant infections (χ2 = 7.948; p = 0.005). Higher CRP showed correlation to unfavourable outcome (p < 0.05). Patients with completely normalized CRP value (n=96) had significantly favourable outcome compared to patients without normalization (χ2 = 5,410; p = 0.02). Patients who received antibiotic therapy for a period of time more than six weeks (n = 91 or 38.4%) had significantly favourable outcome (Corr = -0.159; χ2 = 5,733; p = 0.017). Patients who underwent previous surgeries on the spine, id est 88 patients with postoperative spondylodiscitis, had significantly unfavourable outcome (corr = - 0.155; χ2 = 5,724; p < 0,02) as well as patients with recurrent spondylodiscitis (Corr = -0.184; χ2 = 0,004; p < 0,01) and patients with more comorbidities (p < 0.01). CONCLUSION. Due to the possibility of surgical removal of the infection focus, microbiological diagnosis from the intraoperative specimen, early mobilization of the patient, higher quality of life and better pain control, surgery can be used as first line therapy. Complete healing of infection with significant fall of laboratory infection parameters (leucocyte count and CRP) are essential for successful treatment and impossible to achieve without appropriate antibiotic therapy. Application of antibiotic therapy longer than six weeks as well as normalized CRP showed clear correlation to favourable outcome, while additional infection foci, previous operations of the spine, a severe multimorbidity and high initial CRP were significantly related with unfavourable outcome. Therefore, we recommend operative therapy, screening for concomitant infectious diseases during the primary hospital stay for all patients with CT of thorax and abdomen, trans esophageal echocardiography, as well as clinical examination of nasal and dental cavity, especially in patients who carry the risk for unfavourable outcome. PUBLICATION. Our results have been published: Pojskić M, Carl B, Schmöckel V, Völlger B, Nimsky C, Saβ B. Neurosurgical Management and Outcome Parameters in 237 Patients with Spondylodiscitis. Brain Sci. 2021 Jul 30;11(8):1019. doi: 10.3390/brainsci11081019. PMID: 34439638; PMCID: PMC8394582. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8394582/).