A retrospective study.

Neurological deficits occur in 1/3 of spinal infection cases. Non-specific symptoms can lead to delays in diagnosis. This study reviews outcomes and the timeliness of diagnosis in patients with spinal infection who sustained subsequent spinal cord impairment.

All 40 patients admitted to The Princess Royal Spinal Injuries Centre, Sheffield, UK, between 2016-2018 for rehabilitation for spinal cord impairment secondary to spinal infection.

The average age was 58.6 years (31-85; SD 13.1) with 24 (60%) being male. 36 (90%) had native infections and 3 (7.5%) were acquired post-operatively (1 (2.5%) unknown). 7 patients had been intravenous drug users (17.5%). 50% (20) had previously sought medical attention for the same symptoms. There were long intervals to suspected diagnosis and to MRI (range 0-30 days). 15 (37.5%) patients deteriorated neurologically following admission to hospital; 8 were taking antibiotics at the time of deterioration. None of the patients had normal C-reactive protein levels at presentation. 7 (17.5%) sustained complete spinal cord impairment. 27 (67.5%) were discharged as wheelchair users.

Whilst the majority of patients responded to rehabilitation interventions, they were left with residual life changing disabilities. Among those requiring rehabilitation, delays in diagnosis appear to frequently occur pre-hospital. This could be attributed to a low index of suspicion in the community. Some deteriorated neurologically despite antibiotics. Close neurological monitoring of those suspected or confirmed to have a diagnosis of spinal infection is appropriate. There should be a low threshold for the use of inflammatory markers when investigating back pain.

Vertebral osteomyelitis is a general term for a heterogenous group of spine infections involving the vertebral bone, intervertebral discs, and facet joints. These infections can often spread contiguously to adjacent paraspinal structures, including paravertebral muscles and the epidural space and frequently presents with nonspecific and indolent symptoms, which can delay diagnosis. Treatment can be arduous, requiring prolonged courses of antibiotics often combined with surgical debridement. This review focuses primarily on pyogenic vertebral osteomyelitis in adults, reviewing the pathophysiology, epidemiology, microbiology, diagnosis, and treatment of this infection.

The etiological diagnosis of pyogenic spinal infection is crucial for its precise antibiotic treatment. Traditional methods of detection are often slow and ineffective. In recent times, metagenomic next-generation sequencing (mNGS) has revolutionized pathogen detection, offering a more effective approach to disease management.

Comparing mNGS with microbial culture to comprehensively explore the diagnostic value of mNGS in pyogenic spinal infections.

A multicenter, retrospective observational study.

In a multicenter retrospective observational study, we analyzed the data from 301 patients admitted in four selected hospitals with pyogenic spinal infections from December 2019 to February 2024.

Identification of pathogenic bacteria in patients.

Obtain blood and lesion tissue or pus samples from the enrolled patients for microbial culture, serological and hematological laboratory tests, pathological examination, and mNGS analysis, followed by a comparative analysis of the results.

In our cohort of 301 cases of clinically diagnosed pyogenic spinal infections, 242 yielded etiological evidence. The most common gram-positive bacterium was Staphylococcus aureus, and the most common gram-negative bacterium was Escherichia coli. mNGS showed a significantly higher rate of detection (77.9%) compared with microbial culture (27.2%) with a notable difference (X² = 140.17, P<.001). In culture-negative samples, mNGS could detect pathogens in 73.1% of cases, and in culture-positive samples, it could detect pathogens in 91.5% of cases with 94.7% genus-level concordance. mNGS provided faster results (24-48 h) compared with the culture method (2-7 days).

mNGS serves as a valuable supplement to the culture method and shows potential in identifying the causative pathogen in native pyogenic spinal infections.

Study DesignPrognostic study.ObjectivesThe objective of this study is to identify predictive factors for cloxacillin susceptibility in spinal infections.MethodsA retrospective analysis was conducted using data from January 1, 1997, to December 31, 2021. The study included patients presenting with back pain and either a positive bacterial culture from the spine or radiological evidence of spinal infection (spondylodiscitis and/or epidural abscess) along with positive bacterial blood culture.ResultsAmong 171 patients (127 males, 44 females), 53.2% had Staphylococcus isolates, with 40.4% showing cloxacillin resistance. Lower globulin levels (<33.5 g/L), recent hospitalization within 90 days, and residence in an old age home predicted gram-positive bacteria with cloxacillin resistance and gram-negative bacteria as causative organisms (P<.05). The 30-day and 1-year all-cause mortality rates were 0% and 8.2%, respectively. Higher red cell distribution width (RDW >16.1%) and Charlson comorbidity index (CCI) scores predicted 1-year all-cause mortality (P<.05). Intensive care unit admission was required for 9.9% of patients.ConclusionsThis study identified predictive factors for spinal infection by gram-positive bacteria with cloxacillin resistance and gram-negative bacteria. Patients with lower globulin levels (<33.5 g/L), recent hospitalization within 90 days, or residency in an old age home upon admission should avoid standalone cloxacillin therapy and consider antibiotics with gram-negative coverage. Higher RDW (>16.1%) and CCI scores were associated with increased 1-year all-cause mortality. These findings contribute to treatment decision-making and improving patient outcomes in spinal infections.

As the incidence of de novo spinal infections has risen with increasing global medical complexity and intravenous drug use, so has the uncertainty around standard of care and surgical decision making. Nonoperative management has increased in popularity albeit with frequent failure rates in up to one-third of patients. Although clinical decision making has largely been guided by clinician experience and institutional preference, two recent scoring system-the Spinal Instability Spondylodiscitis Score (SISS) and the Spinal Infection Treatment Evaluation score (SITE) provide a promising potential avenue towards evidence-based pathways.

The aim of the current study was to compare external performance of the SITE and the SISS score in predicting operative decision making in patients with de novo spinal infections seen at a tertiary urban referral center, using real-world clinical decision making as a comparison. A secondary aim was to elucidate areas with low reliability or floor or ceiling effects as possible targets for score improvement.

Retrospective external validation study utilizing consecutive cases from an academic tertiary referral center PATIENT SAMPLE: Adult patients undergoing treatment for spondylodiscitis or spinal epidural abscess OUTCOME MEASURES: Using the surgical intervention as the ground truth, the primary outcomes were performance metrics of the SITE and SISS score including receiver operating characteristic curves, specificity, sensitivity, and interrater reliability for both score and classification. Of note, the SITE score increases in severity with lower scores, whereas the SISS score increases in severity with higher scores.

A panel of three blinded raters scored the clinical data.

Two-hundred thirteen patients were included, of which 62% (144/213) underwent nonoperative medical management and 38% (80/213) underwent operative management. Mean SITE numerical scores were lower (more severe) in the operative group (5.63 vs. 7.45, p<.001). The most frequent categorical group for the SITE score was "severe" in both the operative group (93%, 74/80, mean score 5.63) and the nonoperative group (68%, 90/133, mean score 7.45). The mean SISS score did not differ between operative and nonoperative groups (6.73 vs. 6.25, p=.2). ICC agreement was "almost perfect" for the SITE score (0.86, 95% CI 0.82-0.89) and "substantial" for the SISS score (0.68, 95% CI 0.56-0.76). Performance metrics for the SITE score were "good" (AUC 0.743, 95% CI 0.67-0.81), and for the SISS score were "poor" (AUC 0.557, 95% CI 0.47-0.64). ROC analysis for SITE identified a cutoff score of 6.5 to optimize sensitivity and specificity at 0.692 and 0.700, respectively. If using the established cutoff of 8 for "severe" infection as described in the original scoring system, the sensitivity was 0.813, specificity, 0.504, positive predictive value (PPV) 0.496, and negative predictive value (NPV) 0.817. ROC analysis for SISS similarly proposed a cutoff score of 8.0 which yielded a sensitivity and specificity of 0.350 and 0.797, respectively. If using the established cutoff of 10 for "unstable lesion" as described in the original scoring system, the sensitivity was 0.125, specificity 0.917, PPV 0.476, and NPV 0.635.

This study reports external performance metrics for the SITE and SISS score, demonstrating good performance for SITE and poor performance for SISS in predicting operative intervention with almost perfect SITE and substantial SISS agreement among raters. Ceiling effects may limit clinical utility of the SITE score. Subscales which require raters to determine percent vertebral body involvement or posterolateral involvement performed worse. Future work can focus on further discrimination within the "severe" infection group and improvement of low-performing subscales to improve clinical impact.

A case study of multiple distinct levels of skipped thoracolumbar spine infection was reported in which 13 successful vacuum sealing drainage (VSD) surgeries were treated.

The patient underwent a total of 13 procedures within our medical facility, including five performed under local anesthesia and eight performed under general anesthesia. The source of the ailment was ultimately identified as Enterobacter cloacae. After the last procedure, the patient's symptoms were alleviated, and the recovery process was satisfactory. Three months post-operation, the Japanese Orthopaedic Association scores had improved to 100%. Imageological examination revealed a satisfactory position of internal fixation, and the abnormal signals in the vertebral body and intervertebral space had been eliminated when compared to the pre-operative results.

The study demonstrates that the extreme lateral approach debridement combined with multiple VSD operations is a secure and successful method of treatment for recurrent spinal infection, providing an alternative to traditional surgery.

The use of electrical neuromodulation has often been limited to those with previous back surgery, peripheral neuropathy, and complex regional pain syndrome. Many patients with severe intractable low back pain were thought to be candidates for spinal cord stimulation (SCS), dorsal root ganglion stimulation, or peripheral nerve stimulation but did not meet the criteria. Recently, additional high-level data has supported the use of SCS in non-surgical low back pain (NSLBP), and United States Food and Drug Administration approval has been granted. The American Society of Pain and Neuroscience (ASPN) executive committee realized an unmet need to develop criteria for patient selection for this specific patient population. This is a NEURON project (neuroscience, education, utilization, risk mitigation, optimal outcomes, and neuromodulation), a living guideline for evolving therapies and indications, and is focused on the use of neuraxial stimulation for the treatment of refractory pain.

After board approval, the society accepted nominees for the project, with an emphasis on experience, publication, research, and diversity. The team created an outline for discussion, chose a grading system based on published guidelines, and created consensus points.

The evidence led to several consensus points to best guide patient selection based on the level of evidence and expert opinion. The results will lead to improved safety and efficacy in implanted patients, and to a new standard for best practices.

The selection of patients for implantation in those who have NSLBP should be based on published literature, best practice, and expert opinion. This NEURON project will allow for regular updates to create a living guideline that will allow for better assimilation of information to improve safety and efficacy going forward.

The study assessed the efficacy of percutaneous pedicle screw fixation (PPSF) as a treatment approach for monosegmental pyogenic spondylodiscitis (PS), particularly in patients with compromised health conditions that reduce their ability to endure extensive surgical procedures.

From January 2019 and December 2021, a total of 38 patients with PS who underwent PPSF at our hospital were included in the study. Clinical outcomes were assessed using physical examinations, serological tests, Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and imaging assessments.

The mean duration of PPSF among all patients was 73.9 ± 13.9 min, with an average intraoperative blood loss of 52.4 ± 18.4 mL. Pathogenic bacteria were identified in 17 out of 38 cases, representing a detection rate of 44.7%. The mean follow-up period was 21.3 ± 8.3 months. Postoperative assessment of inflammatory markers indicated that infections were effectively controlled in 33 patients, resulting in symptomatic improvement. However, within 2 to 4 weeks postoperatively, 5 patients required a two-stage anterior debridement-fusion following the initial internal fixation. Compared to those who underwent posterior internal fixation alone, these patients had significantly higher Spinal Instability Spondylodiscitis Scores (12.000 ± 1.000 vs. 9.030 ± 2.114, p < 0.05) and a significantly greater prevalence of preoperative epidural abscesses (80% vs. 12.1%, p < 0.01).

PPSF may serve as a viable option for patients with monosegmental PS, providing a minimally invasive surgical approach for patients who are unable to tolerate traditional open surgery due to compromised health or advanced age. For patients with significant spinal instability or abscess formation, a two-stage anterior debridement-fusion may be required. However, single-stage posterior internal fixation can effectively relieve pain and improve the overall condition of patients, thereby enhancing their ability to tolerate subsequent anterior surgical interventions.

Dual-energy computed tomography (DECT) could combine the high-resolution bone window images made available by multi-detector CT technology with its capability to identify bone marrow edema (BME) in the spine, for diagnosing spondylodiscitis. Our objective was to compare the diagnostic performance of contrast-enhanced MRI and non-contrast DECT to identify spondylodiscitis of the thoraco-lumbar spine.

This prospective study included 77 consecutive participants (39 males; mean age of 61) who underwent DECT and MRI (within 7 days) between January 2020 and October 2023. DECT data were post-processed on a dedicated offline workstation (SyngoVia® VB20) by using a three-material decomposition algorithm. Four radiologists, blinded to clinical data, evaluated non-contrast DECT and contrast-enhanced MRI images. The diagnosis of spondylodiscitis was based on vertebral edema, disc edema, endplate erosions, and paraspinal involvement. Diagnostic accuracy values were calculated by using biopsy as a standard of reference. A multi-reader multi-case analysis was performed.

Biopsy revealed a diagnosis of spondylodiscitis in 46 patients (60%). Thoracic and lumbar spondylodiscitis were diagnosed in 37/46 (80%) and 9/46 (20%) patients, respectively. DECT and MRI overall sensitivity, specificity, and AUC were 0.91, 0.89, and 0.90, and 0.94, 0.93, and 0.93, respectively. At lumbar and thoracic levels, the difference between AUC values between DECT and MRI was not significant (p = 0.15). For DECT and MRI, a very good inter-reader agreement was achieved (k = 0.90 and k = 0.97, respectively).

Contrast-enhanced MRI represents the most accurate imaging tool for the diagnosis of spondylodiscitis. However, only a non-significant drop in diagnostic performance was achieved by evaluating non-contrast DECT images.

Question To compare the diagnostic performance of contrast-enhanced MRI and non-contrast DECT for identifying spondylodiscitis of the thoraco-lumbar spine. Findings MRI was not significantly superior compared to DECT in diagnosing spondylodiscitis, whereas the inter-reader agreement was near perfect for both MRI and DECT. Clinical relevance DECT represents a fast and accurate imaging tool for the demonstration of BME, erosions, and peri-vertebral inflammation in thoraco-lumbar spondylodiscitis.

Spinal endoscopy is a novel minimally invasive spinal surgery technique used in recent years to treat various degenerative spinal diseases. Metagenomic next-generation sequencing (mNGS) is a new method for identifying infectious microorganisms in infectious diseases. We aim to evaluate the application effect of combining spinal endoscopy with mNGS in diagnosing and treating spinal infections.

The clinical data of 62 patients with suspected spinal infectious diseases admitted from January 2020 to December 2023 were retrospectively analyzed. All patients underwent spinal endoscopy to obtain tissue specimens, histopathological examination, routine bacterial culture, and mNGS sequencing. Describe the pathogenic microbial spectrum of spinal infection, and compare the differences in sensitivity (true positive rate) and specificity (true negative rate) between the two detection methods. White blood cell (WBC) erythrocyte deposition rate (ESR), C-reactive protein (CRP), visual analog scale (VAS), Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), and other clinical results were analyzed.

In 62 cases, mNGS, microbiological culture, serologic testing, and pathologic examination results were obtained. 49 cases of spinal infections and 13 cases of non-spinal infections were finally diagnosed clinically. Among the 49 patients with spinal infections, there were 31 cases of purulent bacterial infections, 8 cases of tuberculosis infections, and 10 cases of infections with unspecified etiological microorganisms. Among the 13 cases of non-spinal infections, there were 3 cases of spinal tumors, 6 cases of Modic changes of the endplates, and 4 cases of endplate fracture. The positive rate of microbial culture was 36.73% (18/49), and the positive rate of the mNGS test was 71.43% (35/49), which was statistically different from each other (P < 0.01). The sensitivity of the mNGS test was 71.43%, and the specificity of the mNGS test was 84.62%. At the 3-month follow-up, WBC, ESR, and CRP levels were normalized. The VAS, JOA score, and ODI of the lower back and legs at each follow-up point after surgery were significantly improved compared with those before surgery, and the difference was statistically significant (P < 0.01).

Metagenomic sequencing technology is fast, efficient, and accurate in detecting pathogenic microorganisms, and has high diagnostic value in the diagnosis and treatment of spinal infections. Spinal endoscopic debridement combined with mNGS can achieve good clinical results.

As life expectancy increases worldwide, the elderly population in every country is growing in both the size and proportion. This review aims to provide a comprehensive overview of the microbiology, clinical presentation, diagnostic strategies, and therapeutic approaches to vertebral osteomyelitis, summarizing the latest evidence to guide effective treatment.

A comprehensive literature search was conducted using the Medline and Embase databases to identify relevant studies on vertebral osteomyelitis. The search included the following keywords: "vertebral osteomyelitis," "spinal infection," "discitis," "spondylitis," " spondylodiscitis," and "spinal epidural abscess." Both retrospective and prospective studies, case series, and reviews were considered.

This condition is commonly caused by bacteria such as Staphylococcus aureus or gram-negative bacilli, but can also be caused by other pathogens like fungi and parasites. The onset of vertebral osteomyelitis is insidious, with low specificity in clinical manifestations, often making early diagnosis difficult. Delayed or inadequate treatment may lead to sepsis, permanent neurological damage, or even death. Treatment strategies emphasize the importance of identifying the causative pathogen to guide effective antimicrobial therapy. Current consensus does not advocate for empirical antibiotic treatment unless patients exhibit signs of neurological impairment or severe sepsis. Severe cases involving neurological paralysis, spinal instability, or sepsis may require surgical intervention.

Vertebral osteomyelitis requires prompt diagnosis and treatment for a good prognosis. Delayed diagnosis and treatment can lead to permanent neurological deficits or death. Identifying the causative organism is crucial for guiding appropriate antimicrobial therapy. In addition to conservative and surgical treatments, local drug delivery systems offer new approaches to managing spinal osteomyelitis.

Objectives: Spondylodiscitis can be caused by various microorganisms and has shown a continuous rise in incidence and mortality. The purpose of our study was to analyze the demographic and laboratory data, as well as comorbidities of patients that were surgically treated for spondylodiscitis in our hospital. The causative pathogens involved in the etiology of spinal infections were also assessed. Methods: The study included 92 patients who underwent clinical, radiological, and microbiological analyses including bacterial isolation. According to their culture results, patients were divided into three groups: negative results (n = 29), positive results with Mycobacterium tuberculosis (M. tb.) (n = 26), and positive results with other pathological agents (n = 37). Results: Patients with M. tb. had a significantly lower body mass index (p = 0.022) and were significantly younger (p = 0.024) than the others. The analysis of the complete blood work showed significant differences between the groups regarding fibrinogen levels (p = 0.023), C-reactive protein (p = 0.009), and erythrocyte sedimentation rates (p = 0.042). Results also showed significant differences (p = 0.023) for patients with diabetes mellitus who were more prone to a tuberculosis etiology for their spondylodiscitis compared with patients without the disease. Conclusions: These findings have important implications for adopting individualized treatment strategies underlining the need for identification of patients at high risk for specific causative pathogens.

Paraspinal muscle abscesses are rare, and generally occur due to injections or hematogenous dissemination. Here, we describe a rare case of a paraspinal muscle and the ipsilateral psoas major abscess in the lumbar region that communicated via the interspaces of the costal processes.

An 83-year-old man with poorly controlled diabetes mellitus and no history of puncture complained of right low back pain for the past 2 months. He was diagnosed with pyelonephritis and referred to our department for close examination of the low back pain. Magnetic resonance imaging revealed a paraspinal muscle and an ipsilateral psoas major abscess in the lumbar region, which communicated through the interspaces of the costal processes. A definitive diagnosis was made using percutaneous aspiration and the patient was successfully treated conservatively.

This case is very rare and impressive because the paraspinal muscle abscess directly communicated with the ipsilateral psoas major muscle abscess. Spinal infections should always be considered in the differential diagnosis of low back pain, particularly in the absence of long-term improvement. Local physical examinations are essential when examining patients with low back pain. Conservative treatment is effective, even if the abscess is extensive.

Anterior cord syndrome is a rare yet critical neurological condition that poses significant challenges in clinical management. We present the case of a 71-year-old male with a medical history of hypertension, uncontrolled type II diabetes mellitus, hypothyroidism, and end-stage renal disease requiring dialysis who presented to the emergency department with complaints of chills, back pain, abdominal pain, and vomiting episodes. Based on the severity of the patient's illness, it was decided that inpatient admission would be best. At the beginning of the patient's hospital stay, blood cultures grew methicillin-resistant Staphylococcus aureus. In addition, the results of the MRI revealed progressive vertebral body osteomyelitis and discitis at the T10-T11 level, along with surrounding inflammation and edema. During the patient's hospital stay, the patient's neurological condition worsened, and he presented with the onset of bilateral lower limb flaccid paralysis, numbness, and weakness. An MRI of the thoracic spine with and without contrast revealed worsening osteomyelitis and discitis at T10-T11. Given these findings, neurology and orthopedic surgery were consulted. The neurology team diagnosed the patient with anterior cord syndrome. The orthopedic surgery team recommended decompression and a posterior laminectomy. Due to the patient's pre-existing pulmonary issues, uncontrolled type II diabetes mellitus, and chronic kidney disease, the orthopedic surgery team decided to proceed with a posterior decompression through the transpedicular route. Given the presence of bacteremia, a Hickman catheter was placed in the right subclavian vein for continued IV antibiotic treatment. On the last day of hospitalization, the patient was discharged to a long-term acute care facility for continued treatment. Collaboration amongst hospitalists, infectious disease specialists, neurosurgeons, and rehabilitation teams is required in order to facilitate early recognition of critical clinical symptoms in managing complex MRSA-induced spinal cord infections. The complexity of this case is due to the patient's comorbid conditions. Correlating the symptoms of constipation and bladder dysfunction to a neurogenic cause was a challenge for this patient in the setting of hypothyroidism and opioid usage. In summary, early detection of infection and promptly working with physical therapy are critical in order to prevent catastrophic neurological consequences in patients with multiple comorbidities.

Spondylodiscitis describes an infection of the vertebral body and disc. Clinical presentation is often nonspecific. As a result, imaging plays a crucial role in establishing the diagnosis. The most common associated organism is Staphylococcus aureus. Actinomyces neuii is a gram-positive rod that is primarily known to cause soft tissue infections but has rarely been described in association with spondylodiscitis. At the time of this publication, only 1 other case of A. neuii has been reported in the literature. We present a case report of a diabetic patient diagnosed with spondylodiscitis with cultures demonstrating A. neuii as the most likely causative organism. In our case, no definitive infectious source was identified. The significance of A. neuii spondylodiscitis is unclear. At 1 year follow up, this patient had been successfully treated with antibiotic therapy, but did suffer from significant chronic back pain attributed to the infection. Finally, our case highlights important clinical and imaging findings that may illustrate the elusive nature of this diagnosis.

Patient demographic and clinical characteristics may be factors associated with the success of conservative treatment for pyogenic spondylitis. The ability of imaging findings at initial diagnosis to predict patient outcomes remains unclear. The aim of this study was to investigate the risk factors associated with conversion surgery after conservative treatment for pyogenic spondylitis, with a special focus on the initial computed tomography (CT) findings.

This study enrolled 35 patients with pyogenic spondylitis who underwent CT and magnetic resonance imaging (MRI) at diagnosis and were followed-up for more than 6 months. Patients were diagnosed by MRI, and the degree of bone destruction was assessed on CT cross-sectional images. Vertebral body destruction was classified as grades 0 (almost normal), 1 (endplate irregularity), 2 (vertebral body destruction not involving the posterior wall), and 3 (destruction involving the posterior wall). Patients were divided into four groups based on grade of bone destruction and their clinical characteristics were compared.

1, 11, 11, and 12 patients were classified as grades 0, 1, 2, and 3, respectively. Univariate analysis showed no significant differences in the demographic and clinical characteristics of the four groups. Eighteen (51.4 %) patients had been treated surgically, with the rate of surgical treatment being significantly higher in patients with grade 3 (83.3 %) than in those with grades 0 + 1 (25 %) and grade 2 (45.5 %) (P < 0.05). Multivariate analysis showed that epidural abscess on MRI (odds ratio [OR] 10.8, 95 % confidence interval [CI] 1.68-69.7), grade 3 bone destruction on CT (OR 3.97, 95 % CI 1.21-13.0), and C-reactive protein (CRP) improvement rate after 1 week of treatment (OR 0.95, 95 % CI 0.91-0.99) were risk factors for surgery.

Early surgical treatment should be considered for patients with pyogenic spondylitis who present with an epidural abscess on MRI and bone destruction extending to the posterior wall on CT at the time of diagnosis.

To observe the clinical characteristics of fungal and Brucella infections of the lumbar spine and explore the key points for their differential diagnosis.

The clinical data of 12 patients with fungal infection (the fungal group) and 31 patients with Brucella infection (the Brucella group) of the lumbar spine confirmed by microbiological culture and antigen test were retrospectively analysed. The differences in the clinical characteristics and imaging manifestations were observed between the two groups.

The peripheral blood neutrophil ratio, erythrocyte sedimentation rate, serum total protein and serum globulin levels in the fungal group were higher compared with the Brucella group, while the peripheral blood lymphocyte count, lymphocyte ratio and albumin-globulin ratio were lower in the fungal group compared with the Brucella group (P < 0.05). As for imaging examinations, the proportion of bone destruction centred on the intervertebral disc with surrounding osteosclerosis on computed tomography (CT) imaging showed a statistical difference between the Brucella group and the fungal group (P < 0.05). Fungal infection patients showed more osteosclerosis-free areas around the bone destruction on magnetic resonance imaging (MRI) than Brucella infection patients.

There are certain similarities in clinical manifestations between fungal and Brucella infections of the lumbar spine, but the haematological indices and image features of CT and MRI can effectively differentiate between them, providing guidance for the clinical differential diagnosis.

To retrospectively evaluate the correlation between intradiscal gas and infection in patients percutaneously biopsied for suspected discitis-osteomyelitis.

We retrospectively reviewed all CT-guided discitis-osteomyelitis biopsies performed between 2002 and 2022. Two independent trained musculoskeletal radiologists evaluated for presence of gas on CT and/or MRI within 1 week of the biopsy. Disagreements were resolved by a third musculoskeletal radiologist. CT was considered the gold standard for the detection of intradiscal gas. Pathology, microbiology, and imaging and clinical follow-up were used as the gold standard for presence of infection. Interrater agreement on CT and MRI, sensitivity, and positive predictive value were calculated, using the presence of gas as an indicator (test positive) for "no infection."

There were 284 biopsies in 275 subjects (mean age 58 ± 1.0 (range 4-99) years; 101 (37%) females and 174 (63%) males). Of the biopsies, 12 (4%) were cervical, 80 (28%) were thoracic, 192 (68%) were lumbar, and 200 (70%) were considered true discitis-osteomyelitis based on pathology, imaging, and clinical follow-up. Interrater agreement was excellent for CT (kappa = 0.83) and poor for MRI (kappa =  - 0.021). The presence of gas had a 94% specificity and 76% negative predictive value for the absence of infection.

CT is the preferred method for detecting intradiscal gas. The presence of gas means that discitis-osteomyelitis is unlikely. If intradiscal gas is present in the setting of discitis-osteomyelitis, the gas bubbles tend to be smaller and fewer in number.

This article comprehensively reviews current imaging concepts in spinal infection with primary focus on infectious spondylodiscitis (IS) as well as the less common entity of facet joint septic arthritis (FSA). This review encompasses the multimodality imaging appearances (radiographs, CT, MRI, and nuclear imaging) of spinal infection-both at initial presentation and during treatment-to aid the radiologist in guiding diagnosis and successful management. We discuss the pathophysiology of spinal infection in various patient populations (including the non-instrumented and postoperative spine) as well as the role of imaging-guided biopsy. We also highlight several non-infectious entities that can mimic IS (both clinically and radiologically) that should be considered during image interpretation to avoid misdiagnosis. These potential mimics include the following: Modic type 1 degenerative changes, acute Schmorl's node, neuropathic spondyloarthropathy, radiation osteitis, and inflammatory spondyloarthropathy (SAPHO syndrome).

Although relatively rare, infections related to spinal pain interventions pose significant risks with an increase in the frequency of these procedures. This review investigates the incidence, risk factors, and management of infections following spinal pain interventions, such as epidural steroid injections, nucleoplasty, and facet joint injections. Most of the existing literature comprises case reports and retrospective studies with limited prospective research, owing to the nature of these infections. Our analysis revealed that while the overall infection rate is low, potential complications, such as epidural abscesses and spondylodiscitis, can be severe and life-threatening. The risk factors include advanced age, diabetes, immunosuppression, and multiple spinal procedures. Early diagnosis and timely intervention are critical to prevent long-term morbidity. These findings emphasize the importance of developing standardized diagnostic algorithms and treatment guidelines to support clinicians in managing these infections effectively. Future research should focus on large-scale studies to understand the impact of these infections better and refine clinical management strategies.

To compare the clinical efficacy and prognosis differences between conservative treatment and surgical treatment in patients with non-serious neurologically intact pyogenic spondylitis (Nsi-Nsni-PS), and to provide theoretical reference for the clinical treatment of Nsi-Nsni-PS patients.

A retrospective analysis was conducted on 112 cases of Nsi-Nsni-PS patients treated in our hospital from June 2016 to June 2021. According to different treatment methods, they were divided into conservative treatment group (53 cases) and surgical treatment group (59 cases). The general data, laboratory tests, imaging examinations, length of hospital stay, duration of antibiotic use, VAS for pain before and after treatment, ODI, local kyphotic angle correction of diseased vertebrae, and recurrence rate were collected and analyzed in both groups. SPSS 26.0 statistical software was used for analysis. Measurement data were expressed as mean ± standard deviation, and independent sample t-test or rank sum test was used for comparison between groups, while variance analysis was used for intra-group comparison. Count data were expressed as number (%) and compared between groups using chi-square test or Fisher's exact test. Mann-Whitney U test was used to evaluate the changes in local kyphotic angle between the two groups. A p value < 0.05 was considered statistically significant.

There were no significant differences in general data and imaging characteristics between the two groups (P > 0.05); there were no statistically significant differences in the positive culture rate of pathogens, length of hospital stay, duration of antibiotic use, treatment complications, WBC, CRP, ESR levels at admission and discharge, VAS and ODI at admission and last follow-up between the two groups (P > 0.05). The WBC and CRP levels of patients in the conservative group at discharge were lower than those in the surgical group (P < 0.05), and there was no significant difference in the decrease in inflammatory indicators (WBC, CRP, ESR) between the two groups (P > 0.05). By the last follow-up, the neurological function of patients in both groups had significantly improved compared to admission (P < 0.05), with 12 out of 15 ASIA grade D patients in the conservative group recovering to grade E, and 21 out of 25 grade D patients in the surgical group recovering to grade E, with no worsening of neurological function in either group. The differences in VAS and ODI scores at the last follow-up compared to before treatment were statistically significant in both groups (P < 0.05), and all patients regained normal activity. Compared with before treatment, the correction degree of local kyphotic angle in the surgical group at the last follow-up was 0.93 ± 4.94°, slightly higher than that in the conservative group (-0.83 ± 3.37°), and the difference was statistically significant(P < 0.05).

During our follow-up, we found that both conservative and surgical treatments achieved satisfactory clinical outcomes in patients with Nsi-Nsni-PS. Compared to conservative treatment, surgical intervention did not demonstrate significant advantages in reducing hospitalization time and antibiotic usage duration, increasing pathogen culture positivity rate, lowering treatment complications, or controlling recurrence. However, surgical intervention showed superiority in correcting the local kyphotic angle of spinal lesions, albeit with relatively increased surgical trauma, risks, and treatment costs. At the last follow-up, the surgical group did not exhibit better long-term efficacy. Therefore, when formulating clinical treatment strategies for patients with Nsi-Nsni-PS, it may be preferable to prioritize conservative treatment, supplemented by the use of sensitive or empiric antibiotics for infection management, to improve patient prognosis.

This study evaluates the efficacy of metagenomic next-generation sequencing (mNGS) in diagnosing spinal infections and developing therapeutic regimens that combine mNGS, microbiological cultures, and pathological investigations.

Data were collected from 108 patients with suspected spinal infections between January 2022 and December 2023. Lesion tissues were obtained via C-arm assisted puncture or open surgery for mNGS, conventional microbiological culture, and pathological analysis. Personalized antimicrobial therapies were tailored based on these findings, with follow-up evaluations 7 days postoperatively. The sensitivity and specificity of mNGS were assessed, along with its impact on treatment and prognosis.

mNGS showed a significantly higher positive detection rate (61.20%) compared to conventional microbiological culture (30.80%) and PCT (28%). mNGS demonstrated greater sensitivity (79.41%) and negative predictive value (63.16%) than cultures (25% and 22.58%, respectively), with no significant difference in specificity and positive predictive value. Seven days post-surgery, a significant reduction in neutrophil percentage (NEUT%) was observed, though decreases in white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were not statistically significant. At the last follow-up, significant improved in Visual Analogue Scale (VAS) scores, Oswestry Disability Index (ODI), and Japanese Orthopaedic Association (JOA) scores were noted.

mNGS outperforms traditional microbiological culture in pathogen detection, especially for rare and critical pathogens. Treatment protocols combining mNGS, microbiological cultures, and pathological examinations are effective and provide valuable clinical insights for treating spinal infections.

The aim of this study was to evaluate the influence factors of metagenomic next-generation sequencing (mNGS) negative results in the diagnosed patients with spinal infection. mNGS test was applied in a cohort of 114 patients with suspected spinal infection, among which 56 patients had a final diagnosis of spinal infection. mNGS achieved a sensitivity of 75.0% (95% CI, 61.6% to 85.6%) and a specificity of 84.5% (95% CI, 72.6% to 92.7%), using histopathology and culture results as reference. Diagnosed patients with a negative culture result had lower white blood cell account, percentage of neutrophilic granulocyte, C-reactive protein (all P<0.05) and relatively higher rate of prior antimicrobial treatment history (P=0.059). However, diagnosed patients with a negative mNGS result did not have such difference with mNGS-positive patients, suggesting that mNGS was not strictly limited by the above indicators, which presented the advantages of this technique from another point of view.

Retrospective review.

Spinal intradural extramedullary abscess (SIEA) is a rare disease with an unknown incidence. In this study, we systematically described the clinical course of SIEA in a large cohort with acute onset of neurological illness, assessed the morbidity and mortality rates, and determined the potential risk factors for mortality.

Electronic medical records of patients diagnosed with SIEA at a single institution for the period between September 2005 and December 2020 were retrieved.

Over a period of 15 years, 881 patients with spinal infections were treated either conservatively or surgically at our center, of whom 45 patients (45/881, 5.1%) had SIEA. The overall mean age was 69.6 ± 5.6 years of patients diagnosed with SIEA and all of them underwent posterior decompression via laminectomy. The mean Charlson Comorbidity Index (CCI) was 6.9 ± 2.5, indicating a poor baseline reserve. Progressive neurological decline was observed in all patients (mean motor score, 88.6 ± 9.7). The in-hospital rate and 90-day mortality were 4.4% and 10%, respectively. Mortality was not surgery related. Most importantly, the patients' motor deficits and blood infection parameters significantly improved after surgery. Risk factors for mortality were increased age, comorbidities as measured by CCI, and preoperative motor weakness (MS).

Immediate surgical decompression via laminectomy, with antiseptic irrigation and drainage of the subdural space, followed by antibiotic therapy, appears to be the key to ensuring beneficial clinical outcomes to treatment of rare diseases such as SIEA.

Non-traumatic spinal cord injury (NTSCI) is a term used to describe damage to the spinal cord from sources other than trauma. Neuroimaging techniques such as computerized tomography (CT) and magnetic resonance imaging (MRI) have improved our ability to diagnose and manage NTSCIs. Several practice guidelines utilize MRI in the diagnostic evaluation of traumatic and non-traumatic SCI to direct surgical intervention.

The authors review practices surrounding the imaging of various causes of NTSCI as well as recent advances and future directions for the use of novel imaging modalities in this realm. The authors also present discussions around the use of simple radiographs and advanced MRI modalities in clinical settings, and briefly highlight areas of active research that seek to advance our understanding and improve patient care.

Although several obstacles must be overcome, it appears highly likely that novel quantitative imaging features and advancements in artificial intelligence (AI) as well as machine learning (ML) will revolutionize degenerative cervical myelopathy (DCM) care by providing earlier diagnosis, accurate localization, monitoring for deterioration and neurological recovery, outcome prediction, and standardized practice. Some intriguing findings in these areas have been published, including the identification of possible serum and cerebrospinal fluid biomarkers, which are currently in the early phases of translation.

This study aimed to compare and analyze differences in clinical and magnetic resonance imaging (MRI) findings between tuberculous spondylodiscitis (TbS) and pyogenic spondylodiscitis (PyS), and to develop and validate a simplified multiparameter MRIbased scoring system for differentiating TbS from PyS.

We compared predisposing factors in 190 patients: 123 with TbS and 67 with PyS, confirmed by laboratory tests, culture, or pathology. Data encompassing patient demographics, clinical characteristics, laboratory results, and MRI findings were collected between 2015 and 2020. Data were analyzed using logistic regression methods, and selected coefficients were transformed into an MRI-based scoring system. Internal validation was performed using bootstrapping method.

Univariate analysis revealed that the significant risk factors associated with TbS included thoracic lesions, vertebral destruction > 50%, intraosseous abscess, thin-walled abscess, well-defined paravertebral abscess, subligamentous spreading, and epidural abscess. Multivariate analysis revealed that only thoracic lesions, absence of epidural phlegmon, subligamentous spreading, intraosseous abscesses, well-defined paravertebral abscesses, epidural abscesses, and absence of facet joint arthritis were independent predictive factors for TbS (all p < 0.05). These potential predictors were used to derive an MRI scoring system. Total scores ≥ 14/29 points significantly predicted the probability of TbS, with a sensitivity of 97.58%, specificity of 92.54%, and an area under the curve of 0.96 (95% confidence interval, 125.40-3,257.95).

This simplified MRI-based scoring system for differentiating TbS from PyS helps guide appropriate treatment when the causative organism is not identified.

Thoracic spinal epidural abscess (SEA) is a rare but dangerous condition, and traditional surgical methods are accompanied by extensive trauma and approach-related complications. Here we introduce the technique of full-endoscopic transforaminal debridement and decompression and evaluate its feasibility for treating brucellar thoracic SEA.

We performed thoracic full-endoscopic transforaminal decompression and debridement on two patients with neurological deficits caused by brucellar SEA, which is mainly composed of granulation tissue rather than pus. Postoperative MRI was conducted to confirm the presence of any residual abscess compressing the nerves. Frankel grading was employed to assess the recovery of neurological function, and complications were documented.

There were no occurrences of dural tear, postoperative hematoma, or pulmonary complications. Their neurological function had significantly improved after surgery, and postoperative MRI confirmed no residual abscess compressing the spinal cord. During the 2-year follow-up, one patient achieved complete recovery (from Frankel-C to Frankel-E), while another patient improved from Frankel-A to Frankel-D. Neither patient experienced infection recurrence, instability, nor kyphotic deformity.

We described the novel application of transforaminal endoscopic surgery in brucellar thoracic granulomatous SEA and preliminarily indicated the feasibility of this technique as a minimally invasive alternative to open surgery.

Multiple spinal epidual abscesses with multifocal systemic abscess and multiple joint septic arthritis present with a large infective burden resulting in sepsis, systemic inflammatory dysregulation, and multi-organ failure. This requires pre-operative resuscitation and surgery of greater complexity, longer operative duration, and blood loss, creating challenges to surgical management.

A 69-year-old Chinese female presented with multilevel discrete spinal epidural abscesses along the cervical, thoracic, and lumbar spine, alongside concomitant multifocal systemic abscesses and multiple small joint septic arthritis. She received pre-operative resuscitation to restore organ function, reverse acidosis, and coagulopathy, prior tobefore surgical decompression of selected abscesses and joints under a multidisciplinary team. Remaining sites of infection without significant compression were undrained. The patient recovered well with no residual neurological deficits.

Multifocal infections in critically ill patients require a multidisciplinary team for preoperative resuscitation, joint surgical planning, and prioritiszing surgical interventions to prevent excessive surgical stress to the patient.

This study aimed to explore the clinical efficacy of metagenomic next-generation sequencing (mNGS) in diagnosing and treating suspected spinal infectious diseases.

Between October 2022 to December 2023, a retrospective analysis was performed on patient records within the Department of Spinal Surgery at Guilin People's Hospital. The analysis included comprehensive data on patients with presumed spinal infectious diseases, incorporating results from mNGS tests conducted externally, conventional pathogen detection results, laboratory examination results, and imaging findings. The study aimed to assess the applicability of mNGS in the context of suspected spinal infectious lesions.

Twenty-seven patients were included in the final analysis. Pathogenic microorganisms were identified in 23 cases. The included cases encompassed 1 case of tuberculous spondylitis, 1 case of fungal infection, 3 cases of Brucella spondylitis, 3 cases of viral infection, 9 cases of bacterial infection, and 6 cases of mixed infections. Pathogenic microorganisms remained elusive in 4 cases. The application of the mNGS method demonstrated a significantly elevated positive detection rate compared to conventional methods (85.19% vs. 48.15%, P < 0.05). Moreover, the mNGS method detected a greater variety of pathogen species than traditional methods (Z = 10.69, P < 0.05). Additionally, the mNGS method exhibited a shorter detection time.

mNGS demonstrated significantly higher detection rates for bacterial, fungal, viral, and mixed infections in cases of suspected spinal infectious diseases. The clinical implementation of mNGS could further enhance the efficiency of diagnosing and treating suspected spinal infectious diseases.

In recent years, the incidence of spinal epidural abscesses (SEA) has tripled in number and nonoperative management has risen in popularity. While there has been a shift towards reserving surgical intervention for patients with focal neurologic deficits, a third of patients will still fail medical management and require surgical intervention. Failure to understand long-term quality of life and functional outcomes hinders effective decision making and prognostication.

To describe patterns and associated factors impacting long-term quality of life following treatment of spinal epidural abscess.

Multicenter cohort study at two urban academic tertiary referral centers and two community centers.

Adult patients treated for a spinal epidural abscess.

EuroQoL 5-Dimension 5L (EQ5D), Neuro-Quality of Life Lower Extremity - Mobility (Short Form; NeuroQoL-LE), Patient-Reported Outcomes Measurement Information System Physical Function (short form 4a; PROMIS PF), and PROMIS Global Mental Health score (PROMIS Mental).

Eligible patients were enrolled and administered questionnaires. Multivariable analysis assessed the influence of ambulatory status on HRQL, adjusting for covariates including age, biologic sex, Charlson comorbidity index, intravenous drug use, management approach, and ASIA grade on presentation.

Sixty-one patients were enrolled (mean age 60.5 years, 46% male). Thirty-four patients (58%) underwent operative management. Mean standard deviation (SD) results for HRQL measures were: EQ5D 0.51 (0.37), EQ5D visual analogue scale 60.34 (25.11), NeuroQoL Lower extremity 41.47 (10.64), PROMIS physical function 39.49 (10.07), and PROMIS Global Mental Health 44.23 (10.36). Adjusted analysis demonstrated ambulatory status at presentation, and at 1 year, to be important drivers of HRQL, irrespective of other factors including IVDU and ASIA grade. Patients with independent ambulatory function at 1 year had mean EQ5D utility of 0.65 (95% CI 0.55, 0.75), whereas those requiring assistive devices saw a 49% decrease with mean EQ5D utility of 0.32 (0.14, 0.51). Ambulatory status was associated with global and physical function but did not impact overall health self-assessment or mental health scores.

We found that ambulatory status was the most important factor associated with long-term HRQL regardless of other factors such as ASIA grade or IVDU. Given prior literature demonstrating the protective effect of operative intervention on ambulatory function, this highlights ambulatory dysfunction as a potential indication for surgery and a marker of poor long-term prognosis, even in the absence of focal neurologic deficits. Our work also highlights the importance of optimized long-term rehabilitation strategies aimed to preserve ambulatory function in this high-risk population.

Level III, cohort study.

The clinical incidence of spinal infection is gradually increasing, and its onset is insidious, easily leading to missed diagnosis and misdiagnosis, which may lead to serious complications such as nervous system dysfunction, spinal instability and/or deformity, and cause a huge burden on society and families. Early identification of the causative agent and precision medicine will greatly reduce the suffering of patients. At present, the main pathogenic bacteria that cause spinal infection are Staphylococcus aureus, Streptococcus, Pneumococcus, Escherichia coli, and Klebsiella. There are no reports of spinal infection caused by Pseudomonas fluorescens.

We report a 32-year-old female patient with spinal infection. She presented with flank pain, initially thought to be bone metastases or bone tuberculosis, and had a family background of tumors. Her clinical features and changes in imaging and laboratory tests led to the suspicion of thoracic spine infection. Histopathology of the lesion showed inflammation, tissue culture of the lesion was negative several times, and the possible pathogen - Pseudomonas fluorescens was found after gene sequencing of the lesion. The patient recovered completely after a full course of antibiotic treatment.

This report increases the range of pathogens involved in spinal infections, highlights the unique advantages of gene sequencing technology in difficult-to-diagnose diseases, and validates conservative treatment with a full course of antibiotics for spinal infections without complications.

Postoperative discitis (POD) accounts for 20% to 30% of all cases of pyogenic spondylodiscitis, while POD may be mis-or-under-diagnosed, due to the vague related symptomatology and the non-specific imaging findings. Most studies report infection rate of less than 1%, which increases with the addition of non-instrumented fusion to 2.4% to 6.2%. It remains controversial whether POD is caused by an aseptic or infectious process. Positive cultures are presented only in 42-73% of patients with Staphylococcus species being the most common invading organisms, while Staphylococcus aureus is isolated in almost 50% of cases. The onset of POD symptoms usually occurs at 2-4 weeks after an apparently uneventful operation. Back pain and muscle spasms are usually refractory to bed rest and analgesics. Magnetic Resonance Imaging (MRI) is the most sensitive and specific imaging diagnostic technique. Antimicrobial therapy depends on the results of tissue cultures, and along with bracing represents the mainstay of management. Surgical intervention is necessary in patients failing conservative treatment. For the majority of cases, extensive surgical debridement, antibiotic therapy, and orthosis immobilization are effective in eliminating the infection. According to this, we recommend an Algorithmic approach for the management of POD. Postoperative infections after spinal surgery pose a certain clinical challenge, and in most cases can be treated conservatively. Nevertheless, disability may be persistent, and surgery could be necessary. The purpose of this concise review is to describe the manifestation of post-discectomy infection, its pathogenesis and particularly a rational approach for its management.

This study aimed to compare clinical characteristics and quality of life (QoL) after vertebral osteomyelitis (VO) based on the status of pathogen detection in microbiological sampling.

We conducted a post hoc data analysis from a prospective single-center study in a tertiary referral hospital, including VO patients from 2008 to 2020. Data were collected preoperatively (T0) and 1-year post surgery (T1). The primary outcome was QoL, assessed with the Oswestry Disability Index and Core Outcome Measures Index.

Data from 133 patients with surgically treated thoracic or lumbar VO were evaluated. The pathogen was detected from cultured intraoperative samples in 100 (75.2%) patients (group 1). Culture remained negative in 33 (24.8%) patients (group 2). Quality of life did not differ significantly between the groups at T1. We observed higher preoperative C-reactive protein values and higher rates of spinal empyema at T0 in group 1.

Quality of life improved significantly for all patients at T1, but scores remained comparable to those reported by patients with chronic back pain. Quality of life was not affected by pathogen detection. However, attempts to detect pathogens are still indicated due to the concomitant findings, including bacteremia and epidural abscesses, along with the advantages of targeted antibiotic therapy. The most critical step for detection may be avoiding pre-sampling antibiotic administration. Cite this article as: Beyer F, Wenk B, Jung N, Bredow J, Eysel P, Yagdiran A. An investigation into quality of life improvements after vertebral osteomyelitis depending on the status of pathogen detection. Acta Orthop Traumatol Turc., 2024; 10.5152/j.aott.2024.23073 [Epub Ahead of Print].

Pyogenic spinal infections (PSIs) are severe conditions with high morbidity and mortality. If medical treatment fails, patients may require surgery, but there is no consensus regarding the definition of medical treatment failure.

To determine criteria for defining failure of medical treatment in PSI through an international consensus of experts.

A two-round basic Delphi method study.

One hundred and fifty experts from 22 countries (authors or co-authors of clinical guidelines or indexed publications on the topic) were invited to participate; 33 answered both rounds defining the criteria.

A scale of 1 to 9 (1: no relevance; 9: highly relevant) applied to each criterion.

We created an online survey with 10 criteria reported in the literature to define the failure of medical treatment in PSIs. We sent this survey via email to the experts. Agreement among the participants on relevant criteria (score ≥7) was determined. One month later, the second round of evaluations was sent. An extra criterion suggested by six responders in the first round was incorporated. The final version was reached with the criteria considered relevant and with high agreement.

The consensus definition is: (1) There is an uncontrolled sepsis despite broad spectrum antibiotic treatment, and (2) There is an infection relapse, following a six-week period of antibiotics with clinical and laboratory improvement.

Our definition of failure following nonsurgical treatment of PSI can offer a standardized approach to guide clinical decision-making. Furthermore, it has the potential to enhance scientific reporting within this field.

Spinal endoscopy has evolved significantly since its inception, offering minimally invasive solutions for various spinal pathologies. This study introduces a promising innovation in spinal endoscopy-a single-use digital endoscope designed to overcome the drawbacks of traditional optic endoscopes. Traditional endoscopes, despite their utility, present challenges such as fragility, complex disinfection processes, weight issues, and susceptibility to mechanical malfunctions. The digital endoscope, with its disposable nature, lighter weight, and improved image quality, aims to enhance surgical procedures and patient safety. The digital endoscope system comprises a 30-degree 1000 × 1000 pixel resolution camera sensor with a 4.3 mm working channel, and LED light sources replacing optical fibers. The all-in-one touch screen tablet serves as the host computer, providing portability and simplified operation. Image comparisons between the digital and optic endoscopes revealed advantages in the form of increased field of view, lesser distortion, greater close-range resolution, and enhanced luminance. The single-use digital endoscope demonstrates great potential for revolutionizing spine endoscopic surgeries, offering convenience, safety, and superior imaging capabilities compared to traditional optic endoscopes.

Spinal infection caused by Parvimonas micra (P. micra) is a rare infection. The characteristic imageology includes spondylodiscitis, spondylitis, paravertebral abscess, and epidural abscess. One case of spondylodiscitis of lumbar complicated with spinal epidural abscess caused by P. micra was admitted to the Department of Spinal Surgery, Xiangya Hospital, Central South University on February, 2023. This case is a 60 years old man with lower back pain and left lower limb numbness. MRI showed spondylitis, spondylodiscitis, and epidural abscess. The patient underwent debridement, decompression and fusion surgery. The culture of surgical sample was negative. P. micra was detected by metagenomic next-generation sequencing (mNGS). The postoperative antibiotic treatment included intravenous infusion of linezolid and piperacillin for 1 week, then intravenous infusion of ceftazidime and oral metronidazole for 2 weeks, followed by oral metronidazole and nerofloxacin for 2 weeks. During the follow-up, the lower back pain and left lower limb numbness was complete remission. Spinal infection caused by P. micra is extremely rare, when the culture is negative, mNGS can help the final diagnosis.

Surgical treatment of vertebral osteomyelitis, discitis, and epidural abscesses is indicated in the setting of failure of antibiotic therapy, neurological deficits, epidural abscess, or spinal instability/deformity. Historically, surgical treatment mandated aggressive debridement and spinal stabilization. However, there is growing evidence that direct debridement may not be necessary and may contribute to morbidity. The purpose of this study was to evaluate the efficacy of posterior instrumentation without debridement in treating spinal infections.

A retrospective medical record review was performed to identify patients treated with posterior instrumentation for spontaneous spinal infections. Success of treatment was determined based on postoperative ambulatory status, surgical complications, and need for revision surgery.

Twenty-seven patients treated with posterior-only long-segmented rigid fixation without formal debridement of infected material were included. The most common indications for surgical intervention included spinal instability (67%), neurologic compromise (67%), and failure of prolonged antibiotic treatment (63%). There were no recurrent deep infections in 21 of 22 patients who had long-term follow-up. Four patients required revision surgery, and 3 additional patients requested elective hardware removal. Postoperatively, 70% were ambulatory with no assistive devices postoperatively.

Vertebral osteomyelitis/discitis are challenging medical problems. Single-stage long-segment fusion without formal debridement combined with antibiotics is effective in the management of spontaneous spinal infections.

The present study suggests that acute instrumentation without anterior debridement is associated with a resolution of infection and improvements in neurologic deficits in patient with spontaneous spine infections.

Owing to the lack of evidence on the diagnostics, clinical course, treatment, and outcomes of patients with extremely rare spinal intradural abscess (SIA) and spinal epidural abscess (SEA), we retrospectively analyzed and compared a cohort of patients to determine the phenotyping of both entities.

Over a period of 20 years, we retrospectively analyzed the electronic medical records of 78 patients with SIA and SEA.

The patients with SIA showed worse motor scores (MS scores) on admission (SIA: 20 ± 26 vs. SEA: 75 ± 34, p < 0.001), more often with an ataxic gait (SIA: 100% vs. SEA: 31.8%, p < 0.001), and more frequent bladder or bowel dysfunction (SIA: 91.7% vs. SEA: 27.3%, p < 0.001) compared to the SEA patients. Intraoperative specimens showed a higher diagnostic sensitivity in the SEA patients than the SIA patients (SIA: 66.7% vs. SEA: 95.2%, p = 0.024), but various pathogens such as Staphylococcus aureus (SIA 33.3% vs. SEA: 69.4%) and Streptococci and Enterococci (SIA 33.3% vs. SEA: 8.1%, p = 0.038) were detected in both entities. The patients with SIA developed sepsis more often (SIA: 75.0% vs. SEA: 18.2%, p < 0.001), septic embolism (SIA: 33.3% vs. SEA: 8.3%, p = 0.043), signs of meningism (SIA: 100% vs. 18.5%, p < 0.001), ventriculitis or cerebral abscesses (SIA: 41.7% vs. SEA: 3.0%, p < 0.001), and pneumonia (SIA: 58.3% vs. SEA: 13.6%, p = 0.002). The mean MS score improved in both patient groups after surgery (SIA: 20 to 35 vs. SEA: 75 to 90); however, the SIA patients showed a poorer MS score at discharge (SIA: 35 ± 44 vs. SEA: 90 ± 20, p < 0.001). C-reactive protein (CrP) (SIA: 159 to 49 vs. SEA: 189 to 27) and leukocyte count (SIA: 15 to 9 vs. SEA: 14 to 7) were reduced at discharge. The SIA patients had higher rates of disease-related mortality (SIA: 33.3% vs. SEA: 1.5%, p = 0.002), had more pleural empyema (SIA: 58.3% vs. SEA: 13.6%, p = 0.002), required more than one surgery (SIA: 33.3% vs. SEA 13.6%, p = 0.009), were treated longer with intravenous antibiotics (7 ± 4 w vs. 3 ± 2 w, p < 0.001) and antibiotics overall (12 ± 10 w vs. 7 ± 3 w, p = 0.022), and spent more time in the hospital (SIA: 58 ± 36 vs. SEA: 26 ± 20, p < 0.001) and in the intensive care unit (SIA: 14 ± 18 vs. SEA: 4 ± 8, p = 0.002).

Our study highlighted distinct clinical phenotypes and outcomes between both entities, with SIA patients displaying a markedly less favorable disease course in terms of complications and outcomes.

Early diagnosis of spinal infections remains challenging, and emerging metagenomic next-generation sequencing (mNGS) technology holds promise in addressing this issue. The aim of this study is to investigate the diagnostic efficacy of mNGS in spinal infections.

A total of 78 cases with suspected spinal infections were enrolled in this study, all of whom underwent laboratory, histopathological and mNGS examinations upon admission. Lesion samples were obtained by surgical or C-arm-guided puncture. Sensitivity, specificity, positive predictive value and negative predictive value of culture and mNGS were calculated for statistical analysis.

With histopathological results as the reference, the included 78 patients were categorized into 50 cases in the spinal infection group and 28 cases in the aseptic group. The sensitivity (84%) and negative predictive value (77.14%) of mNGS were significantly higher than those of culture (32% and 44.26%, respectively), whereas no significant differences were observed in terms of specificity and positive predictive value. In the subgroup analysis for Mycobacterium tuberculosis, the sensitivity of mNGS (90.91%) and T-spot (90.91%) was significantly higher than that of culture (0). Additionally, mNGS demonstrated markedly higher specificity (100%) compared to T-spot (85.07%).

This study underscores the substantial advantages of mNGS in terms of diagnostic accuracy and bacterial coverage for spinal infections. The findings provide compelling clinical evidence that supports the enhanced diagnostic efficacy of mNGS.