Introduction
Methods
Literature search
Database | Search | Limits |
---|---|---|
Medline | (Spondylodiscitis [title/abstract] OR vertebral osteomyelitis [title/abstract] OR osteodiscitis [title/abstract] OR (discitis [title/abstract] AND spondylitis [title/abstract])) AND (Treatment [title/abstract] OR therapy [title/abstract] OR antibiotics [title/abstract] OR surgery [title/abstract]) | 2000–2015 English |
Embase | (spondylodiscitis:ab,ti OR (vertebral AND osteomyelitis:ab,ti) OR osteodiscitis:ab,ti OR (discitis:ab,ti AND spondylitis:ab,ti)) AND (treatment:ab,ti OR therapy:ab,ti OR antibiotics:ab,ti OR surgery:ab,ti) AND [2000–2014]/py | 2000–2015 English |
Cochrane library | Spondylodiscitis OR (vertebral AND osteomyelitis) OR osteodiscitis OR (discitis AND spondylitis)) AND (treatment OR therapy OR antibiotics OR surgery) | 2000–2015 English |
Web of science | TS = (Spondylodiscitis OR vertebral osteomyelitis OR osteodiscitis OR (discitis AND spondylitis)) AND TS = (Treatment OR therapy OR antibiotics OR surgery) | 2000–2015 English |
Study selection
Inclusion criteria | Study on the treatment of pyogenic spondylodiscitis in adult patients |
Study design: meta-analysis, RCT, prospective trails, comparative studies, and large case series ≥100 patients | |
Exclusion criteria | Study design: Case reports, case series <100 patients, and review articles |
>50 % tuberculosis, aspergillosis, brucellosis, and postoperative infections | |
Studies on solitary epidural abscesses | |
Children (<18 years) |
Quality assessment
Results
Study selection
Author and year of publication | Treatment | Number of patients | Sex | Age (range/SD) | Follow-up |
---|---|---|---|---|---|
Aagaard 2013 [1] | AB and ST | 100 | 67 male 33 female | 60 (54–69) | 1 year |
Bernard 2014 [2] | AB | 351 | 242 male 109 female | 61 (SD 17) | 1 year |
Hadjipavlou 2000 [3] | AB and ST | 101 | 75 male 26 female | 46 (8–71) one 8 year old patient | ND |
Jensen 1998 [4] | AB | 133 | 70 male 63 female | 65 (6–86) 10 patients <20 years | ND |
Karadimas 2008 [5] | AB and ST | 163 (141 pyogenic, 22 tuberculosis) | 101 male 62 female | 56 (1–83) 12 patients <20 years | 1 year |
Lee 2014 [6] | ST | 26 (24 pyogenic, 2 tuberculosis) | 17 male 9 female | 62 (32–80) | 57 months (16–109) |
Legrand 2011 [7] | AB | 110 | 67 male 43 male | 60.6 (17–86) number of patients <18 ND | 3 months |
Lin 2014 [8] | ST | 45 | 25 male 20 female | 62.4 (ND) | 2 years |
Linhardt 2006 [9] | ST | 22 (17 pyogenic, 5 tuberculosis) | 16 male 4 female | 58.2 (20–75) | 5.4 years |
Loibl 2014 [10] | AB and ST | 105 (102 pyogenic, 3 tuberculosis) | 55 male 50 female | 66.1 (28–88) | 31.5 months (2–198) |
Mulleman 2006 [11] | AB and ST | 136 | 83 male 53 female | 59.8 (16–87) Number of patients <18 ND | ND |
Nasto 2014 [12] | AB and ST | 27 | 18 male 9 female | 57.8 (31–77) | 9 months |
Ozturk 2007 [13] | AB and ST | 56 (40 pyogenic 16 tuberculosis) | 25 male 31 female | 60.8 (38–74) | 6.5 years (3–11) |
Park 2013 [14] | AB and ST | 139 | 79 male 60 female | 65 (55–71) | At least 12 months after completing Antibiotic treatment (AB) |
Parra 2012 [15] | AB and ST | 108 (67 pyogenic, 30 post-operative, 11 tuberculosis) | 49 male 59 female | 67.5 (SD 17) | 6.1 years (2–12) |
Rangaraja 2014 [16] | AB | 61 | 39 male 22 female | 57 (ND) | At least 12 months |
Roblot 2007 [17] | AB | 120 (98 pyogenic, 22 post-operative) | 78 male 42 female | 64 (18–90) | 6 months N = 120, 41 months N = 91 |
Rossbach 2014 [18] | AB and ST | 135 (127 pyogenic, 8 tuberculosis) | 85 male 50 female | 59.9 (16–87) Number of patients <18 ND | ND |
Schomacher 2014 [19] | AB and ST | 37 | 24 male 13 female | 62.4 (42–81) | 20.4 months (6–81) |
Si 2013 [20] | AB and ST | 23 | 13 male 10 female | 38.8 (23–62) | 38 months (24–67) |
Sobottke 2009 [21] | AB and ST | 20 (16 pyogenic, 4 tuberculosis) | 14 male 6 female | 43 (21–67) | 13 months (1–84) |
Valancius 2013 [22] | AB and ST | 196 | 106 male 90 female | 59 (1–89), 8 patients <18 years | 1 year |
Vcelak 2014 [23] | AB and ST | 31 (27 pyogenic, 4 tuberculosis) | 20 male 11 female | 60.5 (21–81) | 1 year |
Wang 2012 [24] | AB and ST | 102 | 60 male 42 female | 49.5 (25–83) | 1 year |
Yong 2008 [25] | AB and ST | 60 | 36 male 24 female | 58 (26–87) | 35.8 months (26–50) |
Characteristics of included studies
Author and year of publication | Study design | Selection bias | Performance bias | Attrition bias | Detection bias | Quality of evidence | Recommendation |
---|---|---|---|---|---|---|---|
Aagaard 2013 [1] | RCS | No | No | Yes | Yes | Very low | Weak |
Bernard 2014 [2] | RCT | No | No | Yes | No | High | Strong |
Hadjipavlou 2000 [3] | RCS | No | Yes | Yes | Yes | Very low | Weak |
Jensen 1998 [4] | RCS | No | Yes | Yes | Yes | Very low | Weak |
Karadimas 2008 [5] | RCS | No | Yes | No | Yes | Very low | Weak |
Lee 2014 [6] | RCoS | Yes | Yes | No | Yes | Very low | Weak |
Legrand 2011 [7] | RCS | No | Yes | Yes | Yes | Very low | Weak |
Lin 2014 [8] | RCoS | No | No | No | Yes | Very low | Weak |
Linhardt 2006 [9] | RCT | No | Yes | Yes | Yes | Moderate | Strong |
Loibl 2014 [10] | RCS | No | Yes | No | Yes | Very low | Weak |
Mulleman 2006 [11] | RCS | No | Yes | No | Yes | Very low | Weak |
Nasto 2014 [12] | RCoS | Yes | No | No | Yes | Very low | Weak |
Ozturk 2007 [13] | RCoS | Yes | Yes | No | Yes | Very low | Weak |
Park 2013 [14] | PCS | No | Yes | No | Yes | Moderate | Strong |
Parra 2012 [15] | RCS | No | Yes | No | Yes | Very low | Weak |
Rangaraja 2014 [16] | RCoS | No | Yes | No | Yes | Very low | Weak |
Roblot 2007 [17] | RCoS | Yes | Yes | Yes | Yes | Very low | Weak |
Rossbach 2014 [18] | RCS | No | Yes | Yes | Yes | Very low | Weak |
Schomacher 2014 [19] | RCoS | Yes | Yes | Yes | Yes | Very low | Weak |
Si 2013 [20] | PCoS | No | No | No | Yes | Moderate | Strong |
Sobottke 2009 [21] | RCoS | No | Yes | Yes | Yes | Very low | Weak |
Valancius 2013 [22] | RCos | Yes | Yes | No | Yes | Very low | Weak |
Vcelak 2014 [23] | RCos | No | No | No | Yes | Very low | Weak |
Wang 2012 [24] | PCos | No | Yes | Yes | Yes | Moderate | Strong |
Yong 2008 [25] | RCos | No | Yes | No | Yes | Very low | Weak |
Quality of included studies
Outcomes of systemic antibiotic treatment
Author and year of publication | Treatment | Positive cultures (%) | Duration of antibiotic treatment | Additional surgical treatment required | Relapse/failure | Mortality (infection related) | Main conclusion of the article |
---|---|---|---|---|---|---|---|
Aagaard 2013 [1] | Antibiotic treatment 6 wks IV 6 wk oral, N = 100 | 90 | 91 days | 41 % | Relapse 4 % Failure 0 % | 8 % (5 %) | Studies evaluating the duration of antibiotic treatment are required |
Bernard 2014 [2] | Antibiotic treatment 6 wk N = 176 | 100 | 6 wk (6–6.6) | ND | Relapse 2.3 % Failure 9.1 % | 8 % (6 %) | 6 weeks of antibiotic treatment is not inferior to 12 weeks of antibiotic treatment |
Antibiotic treatment 12 wk N = 175 | 12 wk (12–13) | ND | Relapse 0 % Failure 9.1 % | 7 % (2 %) | |||
Hadjipavlou 2000 [3] | Antibiotic treatment 6 wk IV and 6 wk oral N = 101 | 75.5 | 12 wks | 54.4 % | Relapse 2 % Failure 0 % | 1 % (ND) | Surgery was preferable to nonsurgical treatment for improving back pain |
Legrand 2011 [7] | Variable antibiotic protocols, mainly IV therapy followed by oral antibiotics, N = 110 | 72.8 | Antibiotics 103 days (42–285) | ND | ND | 1 % (ND) | Wide differences were noted across centers regarding intravenous treatment duration, hospital stay duration, and total treatment duration |
TLSO in 89.1 % | TLSO 81.5 days (SD 63) | ||||||
Parra 2012 [15] | Antibiotic therapy, N = 108 | 69.4 | IV: 5.2 wk (SD 1.43), oral ND | 25 % | Relapse ND Failure ND | 10 % (ND) | Prolonged antimicrobial therapy and the judicious application of timely surgical intervention are essential for an optimal outcome |
Roblot 2007 [17] | Antibiotic therapy <6wk N = 36 | 100 | IV 20 days (SD 16), oral 22 days (ND) | 5.5 % | Relapse 0 % Failure ND | 8 % (3 %) | Antibiotic therapy can be safely shortened to 6 weeks without enhancing the risk of relapse |
Antibiotic therapy >6wk N = 84 | IV 35 days (SD 30), oral 63 days (ND) | 4.8 % | Relapse 7.1 % Failure ND | 12 % (0 %) |
Outcomes of surgical treatment
Author and year of publication | Treatment | Positive cultures (%) | Duration of antibiotic treatment | Additional surgical treatment required | Relapse/failure | Mortality (infection related) | Main conclusion of the article |
---|---|---|---|---|---|---|---|
Lee 2014 [6] | Transpedicular curettage and drainage and posterior stabilization N = 10 | 42 | 91.9 days | 0 % | Relapse 10 % Failure 0 % | 0 % (ND) | Transpedicular curettage and drainage proved to be a useful technique for treating pyogenic spondylodiscitis in patients who were in poor heath |
Combined anterior and posterior surgery N = 26 | 65 days | 6 % | Relapse 0 % Failure 0 % | 0 % (ND) | |||
Lin 2014 [8] | Combined anterior and open posterior N = 25 | 84 | 28–83 days | 0 % | Relapse 8 % Failure 0 % | 0 % (ND) | Anterior debridement and interbody fusion with bone grafting followed by minimally invasive percutaneous posterior instrumentation is an alternative treatment for pyogenic spondylodiscitis |
Combined anterior and percutaneous posterior N = 20 | 28–83 days | 0 % | Relapse 5 % Failure 0 % | 0 % (ND) | |||
Linhardt 2006 [9] | Ventro-dorsal spondylodesis N = 12 | ND | 23.8 wk (3–52) | 0 % | Relapse 8 % Failure 0 % | 25 % (8 %) | Patients with an isolated ventral spondylodesis feel significantly better and experience significantly less pain in the area of spinal fusion than patients with ventro-dorsal fusion |
Ventral spondylodesis N = 10 | 24.1 wk (12–52) | 0 % | Relapse 0 % Failure 0 % | 10 % (0 %) | |||
Ozturk 2007 [13] | Sequential anterior and posterior surgery N = 29 | 100 | 6 wk IV, 3 months oral, TBC 9 months | ND | Relapse ND Failure 0 % | ND (ND) | Simultaneous anterior and posterior surgery is a good alternative procedure. It appears to result in less blood loss, a shorter operative time and fewer complications |
Simultaneous anterior and posterior surgery N = 27 | ND | Relapse ND Failure 0 % | ND (ND) | ||||
Rossbach 2014 [18] | Antibiotic and surgical therapy, N = 125, additional TLSO 46 % | 59 | ND | 55.6 % | Relapse ND Failure ND | ND (ND) | Patients with spondylodiscitis and neurological deficits caused by spinal epidural abces might derive considerable benefit from surgery because their neurological deficits are likely to significantly improve |
Schomacher 2014 [19] | Antibiotic therapy and PEEK cage N = 21 | 70.3 | 2–4 wk IV, 8–10 wk oral | 4.8 % | ND | ND (ND) | The application of TTN- or PEEK-cages does not appear to influence the radiological outcome or risk of reinfection, neither does the extent of removal of the infected disk in this clinical subset |
Antibiotic therapy and TTN cage N = 16 | 2–4 wk IV, 8–10 wk oral | 0 % | ND | ND (ND) | |||
Si 2013 [20] | Dorsal spondylodesis and anterior debridement N = 11 | ND | ND | 0 % | Relapse 8 % Failure 0 % | ND (ND) | Both procedures are safe. Patients with anterior fixation may achieve better postoperative results, such as better well being and less pain |
Anterior debridement and spondylodesis N = 12 | ND | 0 % | Relapse 0 % Failure 0 % | ||||
Vcelak 2014 [23] | Dorsal transmuscular surgery N = 23 | 100 | ND | 8.7 % | Relapse 8.7 % Failure 4.3 % | 4.3 (0 %) | Greater loss of sagittal balance without clinical correlation after a dorsal transmuscular approach |
Two-stage posteroanterior surgery N = 8 | ND | 12.5 % | Relapse 0 % Failure 0 % | 0 % (0 %) | |||
Yong 2008 [25] | Anterior cage followed by pedicle screw fixation N = 37 | 50 | IV min 6 WK, oral min 6 WK | 8.1 % | Relapse ND Failure ND | ND (ND) | Single-stage anterior debridement and cage fusion followed by posterior pedicle screw fixation can be effective in the treatment of pyogenic spondylodiscitis |
Anterior strut followed by pedicle screw fixation N = 23 | IV min 6 WK, oral min 6 WK | 4.3 % | Relapse ND Failure ND | ND (ND) |
Author and year of publication | Treatment | Positive cultures (%) | Duration of antibiotic treatment | Additional surgical treatment required | Relapse/failure | Mortality (infection related) | Main conclusion of the article |
---|---|---|---|---|---|---|---|
Karadimas 2008 [5] | Antibiotic treatment 4 wk IV 1–6 months oral and TLSO (group A N = 70) | 59 | 2–7 months | 11 % (group A) | Relapse ND Failure 0 % | 11.4 % (ND) (group A) | Nonoperative treatment was effective in nine-tenths of the patients. Decompression alone had high a reoperation rate compared to decompression and internal stabilization |
Decompression without (group B N = 56) or with stabilization (group C N = 37) | 2–7 months | 42 % (group B) 16 % (group C) | Relapse ND Failure 0 % | 12.5 % (ND) (group B) 13.5 % (ND) (group C) | |||
Nasto 2014 [12] | Antibiotic therapy and TLSO N = 15 | 100 | 76 days (SD 23) | 0 % | Relapse 0 % Failure 0 % | 0 % (ND) | Surgical stabilization was associated with faster recovery, lower pain scores, and improved quality of life compared with TLSO conservative treatment |
Antibiotic therapy and percutaneous posterior stabilization N = 12 | 84 days (SD 19) | 0 % | Relapse 0 % Failure 0 % | 0 % (ND) | |||
Valancius 2013 [22] | Conservative treatment N = 91, Additional TLSO N = 83 | 72.9 | IV min 2 weeks, oral 3–6 months | 13.1 % | Relapse 7.6 % Failure 13.1 % | 8.7 % (3.3 %) | Conservative measures are safe and effective for carefully selected patients without spondylodiscitic complications. Failure of conservative therapy requires surgery that can guarantee thorough debridement, decompression, restoration of spinal alignment, and correction of instability |
Surgical treatment N = 105 TLSO N = 28 | ND | 17.1 % | Relapse 2.9 % Failure 0.0 % | 1.9 % (0.0 %) |
Systemic antibiotics versus surgical treatment
Author and year of publication | Treatment | Positive cultures (%) | Duration of antibiotic treatment | Additional surgical treatment required | Relapse/failure | Mortality (infection related) | Main conclusion of the article |
---|---|---|---|---|---|---|---|
Jensen 1998 [4] | Antibiotic therapy for S. aureus spondylodiscitis, N = 133 | 100 | 76 days (9–90) TLSO: 121 (24–1425) | ND | Relapse 10 % Failure 13 % | 16 % (ND) | Antibiotic treatment for S. aureus spondylodiscitis is recommended for at least 8 weeks |
Loibl 2014 [10] | Antibiotic therapy N = 46 Surgical and antibiotic therapy N = 56 | 59 | ND | 30 % | Relapse ND Failure ND | 12.4 % (ND) | Infections with S. aureus are associated with a higher rate of complications and a trend toward higher mortality |
Mulleman 2006 [11] | Antibiotic therapy N = 124 Surgical and antibiotic therapy N = 12 Additional TLSO 74 % | 100 | 122 days (56–347) TLSO 126 days (SD 45) | SESD 9.3 % SSD 8.0 % | Relapse ND Failure ND | SESD 4.6 % (ND) SSD 4.6 % (ND) | High incidence of infective endocarditis (26 %) during enterococcal spondylodiscitis |
Park 2013 [14] | Antibiotic therapy for MSSA N = 77 Antibiotic therapy for MRSA N = 62 | 100 | IV: 46 days, oral: 12 days IV: 55 days, oral: 17 days | 29.9 % 27.4 % | Relapse 4.1 % Failure ND Relapse 16.1 % Failure ND | 10.4 % (ND) 8.1 % (ND) | MRSA spondylodiscitis was associated with more frequent persistent bacteremia relapse, and longer hospital stay. Antibiotic therapy for >8 weeks may be benefit patients with MRSA |
Rangaraja 2014 [16] | Vancomycin N = 30 Daptomycin N = 31 | 70.5 | 41 days (ND) 45 days (ND) | 23 % 29 % | Relapse ND Failure 30 % Relapse ND Failure 3 % | 0 % (0 %) | The use of daptomycin resulted in a significantly higher rate of cure in MRSA spondylodiscitis compared with that of vancomycin |
Microorganism-specific treatment
Author and year of publication | Treatment | Positive cultures (%) | Duration of antibiotic treatment | Additional surgical treatment required (%) | Relapse/failure | Infection-related mortality | Main conclusion of the article |
---|---|---|---|---|---|---|---|
Sobottke 2009 [21] | Conservative treatment in HIV patients N = 10 Additional TLSO N = 5 | 100 | ND TLSO = 51 days | 20 | Relapse 0 % Failure 30 % | 0 % (ND) | Operative therapy of spondylodiscitis in HIV positive patients is not associated with an increased surgical complication rate |
Surgical treatment in HIV patients N = 10 Additional TLSO N = 2 | ND TLSO = 51 days | 10 | Relapse 10 % Failure 0 % | 0 % (ND) | |||
Wang 2012 [24] | Antibiotic and surgical treatment in IVDU N = 51, additional halo frame N = 29 | 52 | 62 days (ND) | 4.5 | Relapse ND Failure ND | 0 % (ND) | Among the IVDUs, surgical management is complex with a high incidence of early hardware failure. SSI is significantly more common among non-IVDU |
Antibiotic and surgical treatment in non-IVDU N = 51 | 45 days (ND) | 9.0 | Relapse ND Failure ND | 7.8 % (ND) |