Management of spinal infection: a review of the literature

Abstract

Spinal infection (SI) is defined as an infectious disease affecting the vertebral body, the intervertebral disc, and/or adjacent paraspinal tissue and represents 2-7% of all musculoskeletal infections. There are numerous factors, which may facilitate the development of SI including not only advanced patient age and comorbidities but also spinal surgery. Due to the low specificity of signs, the delay in diagnosis of SI remains an important issue and poor outcome is frequently seen. Diagnosis should always be supported by clinical, laboratory, and imaging findings, magnetic resonance imaging (MRI) remaining the most reliable method. Management of SI depends on the location of the infection (i.e., intraspinal, intervertebral, paraspinal), on the disease progression, and of course on the patient's general condition, considering age and comorbidities. Conservative treatment mostly is reasonable in early stages with no or minor neurologic deficits and in case of severe comorbidities, which limit surgical options. Nevertheless, solely medical treatment often fails. Therefore, in case of doubt, surgical treatment should be considered. The final result in conservative as well as in surgical treatment always is bony fusion. Furthermore, both options require a concomitant antimicrobial therapy, initially applied intravenously and administered orally thereafter. The optimal duration of antibiotic therapy remains controversial, but should never undercut 6 weeks. Due to a heterogeneous and often comorbid patient population and the wide variety of treatment options, no generally applicable guidelines for SI exist and management remains a challenge. Thus, future prospective randomized trials are necessary to substantiate treatment strategies.

Keywords: Intramedullary abscess; Spinal epidural abscess; Spinal infection; Spondylodiscitis; Subdural empyema; Vertebral osteomyelitis.

Conflict of interest statement

Conflict of interest

CT receives speaker honoraria and grant research support from medical implant companies. All other authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

For this type of study, ethical approval is not required.

Figures

Fig. 1

Classification of spinal infection based on the localization of the infection and the affected tissue

Fig. 2

Classification of the types of infection by Thalgott (1991). The aim of the grading is to gauge the severity of the (postoperative) spinal infection and its risk factors [79]

Fig. 3

Male patient, 61 years old, suffering from a septic arthritis of the left ankle joint, chronic alcoholism abuse, presenting with a weakness for abduction (3/5) of the left upper extremity for 2 weeks. Laboratory results show elevated inflammatory parameters (CRP: 5.0 mg/dl, leukocytes: 13.0) Blood cultures reveal Staphylococcus aureus, and Amoxicillin 2.2 g 3× is started. Imaging depicts a spondylodiscitis C4/5 and C5/6 accompanied by intraspinal and prevertebral abscess, plus kyphotic deformity of the cervical spine. (see image a and b) A (1) corporectomy with anterior plating C3–6 and vertebral body replacement (image c) plus (2) dorsal stabilization C3–7 was performed. (image d) Intraoperative biopsy confirms Staph. aureus, Imipenem + Fosfomycin therapy is continued and inflammatory parameters decrease

Fig. 4

Female patient, 73y, suffering from acute myeloid leukemia (AML), presenting with refractory low back pain following a periradicular infiltration 1 month previously. CRP is elevated (15.8 mg/dl), leukocytes are low due to AML (4.1) and blood culture results are negative. Imaging is highly suspicious for spondylodiscitis L5/S1 with a prevertebral abscess (image a and b). Percutaneous instrumentation (L5/S1) is performed (image c) and empiric antibiotic therapy is started (Dalacin + Ciproxin). CRP decreases over time (3.8 mg/dl 2 weeks after instrumentation) and a complete remission of the symptoms after 2 months (image d) is achieved

Fig. 5

Operative treatment algorithm for SI, modified according to Stuer et al. and Hadjipavlou et al. [37, 78]