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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 2  |  Page : 703-708

Prognostic factors in management of postoperative spondylodiscitis


1 Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Neurosurgery, Al Haram Hospital, Menoufia, Egypt

Date of Submission25-Aug-2020
Date of Decision22-Sep-2020
Date of Acceptance03-Oct-2020
Date of Web Publication30-Jun-2021

Correspondence Address:
Yasser I Mahgoub
Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_280_20

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  Abstract 


Background
Spinal infection is an uncommon disease, which may result in serious complications with potentially high morbidity and mortality.
Objective
The aim was to evaluate the outcome of patients with postoperative spondylodiscitis after management in relation to age, sex, general condition, symptoms, signs, radiological findings, type, and time of intervention.
Patients and methods
A prospective study was conducted on 20 patients having postoperative spinal infection managed in the period between June 2017 to June 2019 in the Neurosurgery Department at Menoufia University Hospitals and Al Haram Hospital. Patients with postoperative spinal infection were evaluated neurologically by American Spinal Injury Association (ASIA) score, pain was evaluated by Denis score, and they were followed up radiologically by MRI and radiography for assessment of their neurological integrity, deficits, and outcome.
Results
There was a statistically significant difference between postmanagement Denis pain score, ASIA score, and C-reactive protein as compared with before management (P<0.001). Outcome of the 20 patients was categorized according to Odom's criteria as follows: 12 (60%) patients had excellent outcome, six (30%) patients had good outcome, one (5%) patient had fair outcome, and one (5%) patient had poor outcome.
Conclusion
Among the wide variety of organisms responsible for postoperative spinal infection, we found that Staphylococcus aureus accounted for most of it. The best modality of treatment is medical treatment with antibiotics and surgical management when failure of the medical one or presence of neurological deficits.

Keywords: management, postoperative spondylodiscitis, prognostic factors, surgical intervention


How to cite this article:
Hanafy AM, Rahma HM, Rageh TM, Mahgoub YI, Al Mashad MM. Prognostic factors in management of postoperative spondylodiscitis. Menoufia Med J 2021;34:703-8

How to cite this URL:
Hanafy AM, Rahma HM, Rageh TM, Mahgoub YI, Al Mashad MM. Prognostic factors in management of postoperative spondylodiscitis. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:703-8. Available from: http://www.mmj.eg.net/text.asp?2021/34/2/703/319684




  Introduction Top


Spinal infection is an uncommon disease, which may result in serious complications with potentially high morbidity and mortality [1]. Spinal infection encompasses a spectrum of pathologic entities, including intervertebral disc space infection, vertebral osteomyelitis, spinal epidural abscess, spinal subdural empyema, and intramedullary spinal cord abscess [2]. It has been noted that spontaneous disc space infection is more common in children, whereas pyogenic vertebral osteomyelitis primarily affects adults [2]. Pathogens can infect the spine via three routes: hematogenous spread, direct external inoculation, and/or spread from contiguous tissues. The hematogenous arterial route is predominant, allowing seeding of infection from distant sites into the vertebral column [1].

Primary risk factors of spinal infection include diabetes mellitus, extraspinal infection, especially urinary tract infections, long-term steroid drug use, malignancy, and alcoholism. Additional risk factors are acquired immunodeficiency syndrome infection and chemotherapy treatment [3]. The symptoms of spinal infection are non-specific. Back or neck pain is very common, and fever is less commonly experienced and occurs in only approximately half of the patients [4]. Diagnosis should be supported by clinical, laboratory, and imaging findings [5]. The erythrocyte sedimentation rate (ESR) is also a sensitive marker for infection but has low specificity, as ESR is still increased in 50% of patients with good clinical outcome [3]. Procalcitonin is a promising marker to distinguish between bacterial and nonbacterial infection [6].

MRI remains the most reliable method to diagnose spondylodiscitis, owing to its high sensitivity (96%), high specificity (94%), and capability to provide detailed data on paraspinal tissues and epidural space [7]. Blood cultures and imaging can be inconclusive or false negative; therefore, a definite confirmation of spinal infection can only be attained by microscopic or bacteriological examination of the affected tissue [5]. Conservative management consists of antimicrobial therapy and nonpharmacological treatment such as physiotherapy and immobilization [8]. Indications of surgical intervention include failure of conservative management, compression of neural elements, spinal instability owing to extensive bony destruction, or severe kyphosis [9]. Therefore, this study aims to evaluate the outcome of patients with postoperative spondylodiscitis after management in relation to age, sex, general condition, symptoms, signs, radiological findings, type, and intervention time.


  Patients and methods Top


This was a prospective study conducted on 20 patients having postoperative spinal infection managed during June 2017 till June 2019 in the Neurosurgery Department at El Menoufia University Hospitals and Al Haram Hospital. The treatment modalities included conservative management by medical treatment with antibiotics according to pathogens and surgical decompression with or without fixation. Surgical decompression with or without fixation can be achieved either through an anterior approach, posterior approach, or combined.

Sample size

It was calculated using PASS 11.0 Kaysville, Utah, USA and based on past review of literature by Silber et al. [10], who estimated the prevalence of postoperative spondylodiscitis, showing the total prevalence ranged from 1 to 5%. The sample size has been calculated using the following equation: n−(χ2 × P × Q)/D2 at CT 95% assuming = 0.05 (standard value of 1.96), we calculated that we would need 20 patients with striae distensae to achieve a power of 80% (0.8).

Ethical consideration

The study was approved by the Ethical Committee of Menoufia Faculty of Medicine, and an informed consent obtained from all patients before the study was commenced.

Inclusion criteria were patients of all ages and sexes who had postoperative spinal infection in the form of spondylodiscitis, discitis, and spinal epidural abscess confirmed by clinical, laboratory, and radiological data.

Exclusion criteria included patients who had spontaneous spinal infection.

Preoperative evaluation for patients was done, which included full details history; neurological symptoms, including pain, local or radiating; and symptoms of motor affection, sensory affection, and/or sphincteric disturbance. Pain was evaluated by Denis functional pain scale. Previous surgeries, medications received, previous irradiation, and other associated medical disorders were also noted. Complete general examination was performed for all patients.

A fully detailed neurological examination included sensory examination, including pain, touch, temperature, perianal sensation, deep sensation, and joint sensation; motor examination for the motor power and reflexes for all patients; sphincteric examination; and neurological deficits of limbs, which were evaluated by ASIA score [11]. Routine laboratory investigations included complete blood count, blood sugar, liver, kidney functions, Prothrombin Time (PT), Platelet count (PC), International Normalized Ratio (INR), serum sodium and potassium, total leukocytic count, ESR, and C-reactive protein (CRP). All patients had cardiopulmonary evaluation and ECG [12]. Preoperative plain radiography (anteroposterior and lateral views) was used as a routine screening for all patients, including both computed tomography scan and MRI [13]. Options used for conservative management consists primarily of analgesics and bed rest followed by progressive ambulation. Antibiotics were given intravenously for 6 weeks and followed by 6 weeks of oral antibiotic treatment (linezolid 600 mg OD + ciprofloxacin 500 mg BID). Patients who had evident lower limb weakness rendering them not ambulant were closely monitored for proper hydration and given prophylactic dose of short-acting anticoagulants 40 units/day in average weight patients and 80 units in severely obese patients; these anticoagulants were stopped 12 h before surgery [14]. Patients who had history of medical disorders were subjected to proper assessment and given the proper corresponding medications [14].

All patients were given 1 g of third-generation cephalosporin 6 h before the surgery and another intraoperative dose [15]. Surgical steps included epidural abscess evacuation with sample for culture and sensitivity, debridement and removal of all necrotic tissues, and fixation in case of instability [16].

Patients with cardiac problems and morbid obesity were kept in an intermediate care unit for 24 h postoperatively and then transferred to the regular patients ward. Hemoglobin, serum electrolytes, renal functions, and hepatic functions were performed in the early postoperative period, and fluid balance was recorded throughout the period of hospital stay. Patients were allowed to sit and walk with brace during movement and take it off before going to sleep. All patients were subjected to a complete and detailed postoperative neurological and clinical evaluation, comprising motor and sensory functions. Patients having motor weakness were closely monitored for proper hydration, and prophylactic anticoagulants were resumed in addition to physiotherapy, patients were given empirical IV antibiotics. Patients were also continued on steroids in certain cases in gradual tapering dose [17].

All patients were followed up at intervals of 1 week postoperative, 3 months, 6 months, and whenever possible, as some patients did not come at their scheduled follow-up dates. Follow-up included detailed neurological examination to detect any new neurological deficits.

Outcome of patients was graded according to the patients' clinical and functional status in the last follow-up visit [18].

Statistical analysis

Data were tabulated and analyzed using SPSS version 17 software (SPSS Inc, Chicago, Illinois, USA). Categorical data were presented as number and percentages. Quantitative data were expressed as mean ± SD and range. The Wilcoxon test was used in nonparametric paired data. P less than 0.05 was considered statistically significant.


  Results Top


In this study, male to female ratio was 1.5 : 1. Mean age of patients was 47.90 ± 11.64 years. Of 20 patients, 14 patients had at least one confounding factor: five patients had diabetes mellitus, four patients were smokers, three patients had drug addiction history, and two patients had IHD [Table 1]. There were three (15%) patients with cervical spine infection, 16 (80%) patients with lumbar spine infection, and only one (80%) patient with dorsal spine infection [Table 2]. Among 20 patients, seven (35%) cases underwent conservative management, whereas 13 (65%) patients underwent surgical management. Timing of surgical intervention ranged from 2 to 90 days, with a mean of 20.08 ± 26.86 days. In surgically managed patients, seven (53.8%) cases had neurological deficit, two (15.4%) cases failed medical treatment, two (15.4%) cases had severe pain not responding to analgesics, and two (15.4%) cases had spinal instability. Among 13 patients who underwent surgical intervention, three cases underwent anterior approach with fixation, eight cases underwent posterior decompression with fixation, and two patients underwent posterior decompression with debridement [Table 3]. Moreover, there was a statistically significant difference of postmanagement Denis pain score, ASIA score, and CRP compared with before management (P<0.001) [Table 4]. Regarding outcome, 12 (60%) patients had excellent outcome, six (30%) patients had good outcome, one (5%) patient had fair outcome, and one (5%) patient had poor outcome [Table 5].
Table 1: Distribution of the studied cases according to sex, age, and medical history

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Table 2: Premanagement MRI of studied cases

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Table 3: Management plan, timing of surgical intervention, indications of surgical, and type of surgical approach in the studied cases

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Table 4: Comparison between premanagement and postmanagement Denis pain score, ASIA score, and CRP

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Table 5: Distribution of cases according to the outcome

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  Discussion Top


In this study, male: female ratio was 1.5 : 1, and the mean age was 47.90 ± 11.64 years. Similar findings were reported by Jain et al. [19], who reported seven (58%) patients were males, and the mean age was 42 ± 7.15 years. Moreover, Singh et al. [20] found 71% were males and 29% were females. In addition, diabetes mellitus was the most common disease occurring in five (25%) patients, followed by four (20%) patients were smoker, similar to Jain et al. [19] Other large series have also substantiated the role of diabetes mellitus as a risk factor for the development of spinal infections [21],[22], but Zhang et al. [23] noted that the major risk factors in their patients were un-standard lumbar procedure, such as radiofrequency ablation and chemonucleolysis (57%). In this study, the premanagement pain Denis score ranged from P5 to P3, where six (30%) patients were P5, 10 (50%) patients were P4, and four (20%) patients were P3. Moreover, 13 (65%) patients were ASIA score E, five (25%) patients were ASIA score D, and two (10%) patients were ASIA score C. Similarly, Waheed et al. [24] found 29 (63.9%) patients were ASIA score E, 11 (25%) patients were ASIA score D, and four (11.1%) patients were ASIA score C. In addition, Jain et al. [19] found 63% of patients were ASIA score E, 26% of patients were ASIA score D, and 11% of patients were ASIA score C.

In the current study, there were four (20%) patients with CRP 96, nine (45%) patients with CRP 48, five (25%) patients with CRP 24, one (5%) patient with CRP 12, and one (5%) patient with CRP 6. Mean premanagement CRP level was 47.70 ± 28.24 mg/dl. Similarly, Waheed et al. [24] found the mean premanagement CRP level was 25.7 ± 13.70 mg/dl. In addition, Zhang et al. [23] noted that mean premanagement CRP was 71.72 ± 10.73 mg/dl. So, one of the most dependable markers of inflammation is CRP, as levels of CRP follow a predictable pattern following discectomy, as previously reported in many studies such as Tschugg et al. [5] and Singh et al. [20]. Tschugg et al. [5] reported that 47 of 55 patients (85%) underwent surgical management, whereas 8 of 55 patients (15%) underwent conservative management. Bed rest with IV antibiotics followed by oral antibiotics has been the traditional conservative treatment strategy for spondylodiscitis. Keeping in mind the limited diffusion of antibiotics across disc space, a prolonged antibiotic regimen seems logical [25],[26].

In the current study, the timing of surgical intervention that dated from signs of postoperative sponylodiscitis and second surgery ranged from 2 to 90 days with a mean of 20.08 ± 26.86 days. Similarly, Moon et al. [27] found the time between signs of postoperative spondylodiscitis and second surgery ranged from 2 days to 6 months. Moreover, Tschugg et al. [5] found mean time was 15.8 ± 10 days. In our study in surgically managed patients, 53.8% had neurological deficit, 15.4% failed medical treatment, 15.4% had severe pain not responding to analgesics, and 15.4% had spinal instability. This was the same as reported by Chen et al. [9] and Sobottke et al. [28] Indications for surgical intervention include compression of neural elements, spinal instability owing to extensive bony destruction, severe kyphosis, failure of conservative management, and the presence of intractable pain. Most but not all authors consider the presence of epidural abscess as an indication for surgery, even in the absence of neurological deficits [28].

Regarding Denis pain score, 14 (70%) patients were P1 and six (30%) patients were P2. In addition, 85% of patients had ASIA score E and 15% had ASIA score D. However, 65% of the patients had CRP less than 6, 25% with CRP 12, 5% with CRP 24, and 5% with CRP 48. Similarly, Jain et al. [19] found 86% of patients were ASIA score E and 14% were ASIA score D. Moreover, Zhang et al. [23] found mean postmanagement CRP became 7.61 ± 2.31. In our study, there was a statistically significant difference in postmanagement Denis pain score, ASIA Score, and CRP compared with before management. Similarly, Jain et al. [19] and Zhang et al. [23] found premanagement CRP was 71.72 ± 10.73 and postmanagement CRP was 7.61 ± 2.31 (P < 0.05). In our study, 12 (60%) patients showed excellent outcome, six (30%) patients had good outcome, one (5%) patient had fair outcome, and one (5%) patient had poor outcome. However, Jain et al. [19] reported that four (33%) patients experienced excellent outcome, six (50%) patients as good outcome, and two (17%) patients as fair outcome. Despite the advances, still the prognosis of postoperative spondylodiscitis is tentative [23]. However, Basu et al. [29] and Santhanam and Lakshmi [30] reported good outcomes in all their patients, who resumed their normal daily activities within 6 months.

The present study suggested that postoperative spondylodiscitis can be managed medically and/or surgically, and surgical intervention should be reserved only for the resistant cases and those with clear indications for surgery.


  Conclusion Top


Among the wide variety of organisms responsible for postoperative spinal infection, we found that Staphylococcus aureus accounted for most of it. The best modality for treatment is medical treatment with antibiotics and surgical management when failure of the medical one or presence of neurological deficits.

Recommendations

Diabetes and smoking were the most significant risk factors for the development of postoperative spondylodiscitis. Moreover, early diagnosis is the key, as appropriate management is the key to the successful outcome. The decrease in CRP following treatment and the clinical improvement further strengthened the potential of these two parameters as important prognostic markers. Nevertheless, further studies with a larger sample size and longer follow-up are needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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