Turkiye Klinikleri Journal of Medical Sciences

.: ORIGINAL RESEARCH
Spondilodiskitiste Cerrahi Tedavi ve Epidemiyolojik Veriler: Klinik Çalışma
Surgical Treatment and Epidemiological Data in Spondylodiscitis: Clinical Study
Emre ÖZKARAa , Gültekin BAŞb , Tuğçe GÖRa , Zühtü ÖZBEKa
aEskişehir Osmangazi Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi ABD, Eskişehir, Türkiye
bÖzel Ümit Hastanesi, Beyin ve Sinir Cerrahisi Kliniği, Eskişehir, Türkiye
Turkiye Klinikleri J Med Sci. 2023;43(4):333-42
doi: 10.5336/medsci.2023-99968
Article Language: TR
Full Text
ÖZET
 Amaç: Spondilodiskitis, her ne kadar nadir görülen bir omurga sorunu olsa da yüksek morbiditeye sahip, uzun ve ekonomik açıdan yüksek sağlık harcamalarına neden olan özellikle cerrahi tedavide tam kabul görmüş algoritmaları olmayan ciddi bir omurga-omurilik hastalığıdır. Spondilodiskitis; diskit, osteomyelit, epidural apse, menenjit, subdural ampiyem ve spinal kord apsesini içeren bir spektruma sahiptir. Konservatif tedavi doğru alınan mikrobiyolojik örnekleme sonrası uygun antibiyoterapinin verilmesi, hastanın immobilizasyonu, klinik ve radyolojik açıdan omurganın yapısının yakın izlenmesi şeklindedir. Minimal invaziv işlemlerle örneklemenin yapılamadığı, klinik açıdan ciddi ağrı ve/veya nörolojik defisit varlığında, apse formasyonu oluştuğunda, omurgada deformatik değişiklikler varlığında cerrahi tedavi gerekli hâle gelir. Bu çalışmada, cerrahi tecrübelerimizi ve yaklaşımlarımızı bildirerek literatüre katkı sağlamanın yanında hastalığın kendi popülasyonumuzdaki sıklığı, morbiditesi, enfektif ajanın tespiti, prognozu gibi epidemiyolojik verilerin elde edilmesini sağlaması amaçlanmıştır. Gereç ve Yöntemler: 2012-2022 yılları arasında kliniğimizde spondilodiskitis tanısı alıp tedavi uygulanan 52 erişkin hastanın klinik ve radyolojik özellikleri, laboratuvar bulguları, yapılan tedaviler çalışmaya dâhil edilmiştir. Bulgular: On dört (%26) hastanın yapılan açık cerrahi ile örneklemesinde patojen bakteri tespit edilememekle beraber alınan patoloji incelemeleri iltihabi granülasyon dokusu ile uyumlu gelen hastalardı. Diğer grupta 10 Mycobacterium tuberculosis, 6 Brucella, 1 Candida glabrata üremesi oldu. Yirmi bir hasta piyojenik spondilodiskitli hastalardı. Piyojenik spondilodiskitli hastaların 8'i Staphylococcus aureus, diğer 13 hastada etkenler Staphylococcus epidermidis, Staphylococcus hominis, Escherichia coli, Pseudomonas, Acinetobacter'dir. Sonuç: Spondilodiskitis, multidisipliner yönetimi olan, hastaya göre değişen cerrahi yaklaşımları gerektiren uzun süreli ve yüksek sağlık maliyeti olan bir hastalıktır.

Anahtar Kelimeler: Diskitis; omurga; sinir cerrahisi yöntemleri
ABSTRACT
 Objective: Although spondylodiscitis is a rare spinal problem, it is a serious spinal-spinal disease with high morbidity, long and economically high health expenditures, especially in surgical treatment, which does not have fully accepted algorithms. Spondylodiscitis; It has a spectrum that includes discitis, osteomyelitis, epidural abscess, meningitis, subdural empyema, and spinal cord abscess. Conservative treatment consists of administering appropriate antibiotic therapy after correct microbiological sampling, immobilization of the patient, and close monitoring of the structure of the spine in clinical and radiological terms. Surgical treatment becomes necessary in the presence of clinically severe pain and/or neurologic deficit, in the presence of abscess formation, in the presence of deformative changes in the spine, where sampling cannot be performed with minimally invasive procedures. In this study, it is aimed to contribute to the literature by reporting our surgical experience and approaches, as well as to provide epidemiological data such as the frequency of the disease in our population, morbidity, detection of the infective agent, and prognosis. Material and Methods: The clinical and radiological features, laboratory findings, and treatments of 52 adult patients diagnosed with spondylodiscitis and treated in our clinic between 2012-2022 were included in the study. Results: Although pathogenic bacteria could not be detected in the open surgery sampling of 14 patients (26%), the pathology examinations were found to be compatible with inflammatory granulation tissue. In the other group, there were 10 Mycobacterium tuberculosis, 6 Brucella, 1 Candida glabrata growth. 21 patients were patients with pyogenic spondylodiscitis. Eight of the patients with pyogenic spondylodiscitis were Staphylococcus aureus, and the other 13 patients had Staphylococcus epidermidis, Staphylococcus hominis, Escherichia coli, Pseudomonas, Acinetobacter. Conclusion: Spondylodiscitis is a disease with a long-term and high health cost that requires multidisciplinary management and surgical approaches that vary according to the patient.

Keywords: Diskitis; spine; neurosurgical procudures
REFERENCES:
  1. Valancius K, Hansen ES, Høy K, Helmig P, Niedermann B, Bünger C. Failure modes in conservative and surgical management of infectious spondylodiscitis. Eur Spine J. 2013;22(8):1837-44. [Crossref]  [PubMed]  [PMC] 
  2. Mavrogenis AF, Megaloikonomos PD, Igoumenou VG, Panagopoulos GN, Giannitsioti E, Papadopoulos A, et al. Spondylodiscitis revisited. EFORT Open Rev. 2017;2(11):447-61. [Crossref]  [PubMed]  [PMC] 
  3. Gasbarrini AL, Bertoldi E, Mazzetti M, Fini L, Terzi S, Gonella F, et al. Clinical features, diagnostic and therapeutic approaches to haematogenous vertebral osteomyelitis. Eur Rev Med Pharmacol Sci. 2005;9(1):53-66. [PubMed] 
  4. Skaf GS, Domloj NT, Fehlings MG, Bouclaous CH, Sabbagh AS, Kanafani ZA, et al. Pyogenic spondylodiscitis: an overview. J Infect Public Health. 2010;3(1):5-16. [Crossref]  [PubMed] 
  5. Hsieh PC, Wienecke RJ, O'Shaughnessy BA, Koski TR, Ondra SL. Surgical strategies for vertebral osteomyelitis and epidural abscess. Neurosurg Focus. 2004;17(6):E4. [Crossref]  [PubMed] 
  6. Schuster JM, Avellino AM, Mann FA, Girouard AA, Grady MS, Newell DW, et al. Use of structural allografts in spinal osteomyelitis: a review of 47 cases. J Neurosurg. 2000;93(1 Suppl):8-14. [Crossref]  [PubMed] 
  7. Rea GL, McGregor JM, Miller CA, Miner ME. Surgical treatment of the spontaneous spinal epidural abscess. Surg Neurol. 1992;37(4):274-9. [Crossref]  [PubMed] 
  8. Dimar JR, Carreon LY, Glassman SD, Campbell MJ, Hartman MJ, Johnson JR. Treatment of pyogenic vertebral osteomyelitis with anterior debridement and fusion followed by delayed posterior spinal fusion. Spine (Phila Pa 1976). 2004;29(3):326-32; discussion 332. [Crossref]  [PubMed] 
  9. Butler JS, Shelly MJ, Timlin M, Powderly WG, O'Byrne JM. Nontuberculous pyogenic spinal infection in adults: a 12-year experience from a tertiary referral center. Spine (Phila Pa 1976). 2006;31(23):2695-700. [Crossref]  [PubMed] 
  10. Yang SC, Fu TS, Chen HS, Kao YH, Yu SW, Tu YK. Minimally invasive endoscopic treatment for lumbar infectious spondylitis: a retrospective study in a tertiary referral center. BMC Musculoskelet Disord. 2014;15:105. [Crossref]  [PubMed]  [PMC] 
  11. Devkota P, Krishnakumar R, Renjith Kumar J. Surgical management of pyogenic discitis of lumbar region. Asian Spine J. 2014;8(2):177-82. [Crossref]  [PubMed]  [PMC] 
  12. Bydon M, De la Garza-Ramos R, Macki M, Naumann M, Sciubba DM, Wolinsky JP, et al. Spinal instrumentation in patients with primary spinal infections does not lead to greater recurrent infection rates: an analysis of 118 cases. World Neurosurg. 2014;82(6):e807-14. [Crossref]  [PubMed] 
  13. Mohamed AS, Yoo J, Hart R, Ragel BT, Hiratzka J, Hamilton DK, et al. Posterior fixation without debridement for vertebral body osteomyelitis and discitis. Neurosurg Focus. 2014;37(2):E6. [Crossref]  [PubMed] 
  14. Chen HC, Huang TL, Chen YJ, Tsou HK, Lin WC, Hung CH, et al. A minimally invasive endoscopic surgery for infectious spondylodiscitis of the thoracic and upper lumbar spine in immunocompromised patients. Biomed Res Int. 2015;2015:780451. [Crossref]  [PubMed]  [PMC] 
  15. Tschöke SK, Fuchs H, Schmidt O, Gulow J, von der Hoeh NH, Heyde CE. Single-stage debridement and spinal fusion using PEEK cages through a posterior approach for eradication of lumbar pyogenic spondylodiscitis: a safe treatment strategy for a detrimental condition. Patient Saf Surg. 2015;9:35. [Crossref]  [PubMed]  [PMC] 
  16. Shetty AP, Aiyer SN, Kanna RM, Maheswaran A, Rajasekaran S. Pyogenic lumbar spondylodiscitis treated with transforaminal lumbar interbody fusion: safety and outcomes. Int Orthop. 2016;40(6):1163-70. [Crossref]  [PubMed] 
  17. Kothari MK, Shah KC, Tikoo A, Nene AM. Surgical management in elderly patients with tuberculous spondylodiscitis: ten year mortality audit study. Asian Spine J. 2016;10(5):915-9. [Crossref]  [PubMed]  [PMC] 
  18. Turel MK, Kerolus M, Deutsch H. The role of minimally invasive spine surgery in the management of pyogenic spinal discitis. J Craniovertebr Junction Spine. 2017;8(1):39-43. [Crossref]  [PubMed]  [PMC] 
  19. Martín-Alonso J, Delgado-López PD, Castilla-Díez JM, Martín-Velasco V, Galacho-Harriero AM, Ortega-Cubero S, et al. Papel de la cirugía en el tratamiento de las espondilodiscitis espontáneas: experiencia en 83 casos consecutivos [Role of surgery in spontaneous spondylodiscitis: Experience in 83 consecutive patients]. Neurocirugia (Astur: Engl Ed). 2018;29(2):64-78. Spanish. [Crossref]  [PubMed] 
  20. Waheed G, Soliman MAR, Ali AM, Aly MH. Spontaneous spondylodiscitis: review, incidence, management, and clinical outcome in 44 patients. Neurosurg Focus. 2019;46(1):E10. [Crossref]  [PubMed] 
  21. Tsantes AG, Papadopoulos DV, Vrioni G, Sioutis S, Sapkas G, Benzakour A, et al; World Association Against Infection in Orthopedics and Trauma W A I O T Study Group on Bone and Joint Infection Definitions. Spinal infections: an update. Microorganisms. 2020;8(4):476. [Crossref]  [PubMed]  [PMC] 
  22. Aljawadi A, Jahangir N, Jeelani A, Ferguson Z, Niazi N, Arnall F, et al. Management of pyogenic spinal infection, review of literature. J Orthop. 2019;16(6):508-12. [Crossref]  [PubMed]  [PMC] 
  23. Silber JS, Anderson DG, Vaccaro AR, Anderson PA, McCormick P; NASS. Management of postprocedural discitis. Spine J. 2002;2(4):279-87. [Crossref]  [PubMed] 
  24. Duarte RM, Vaccaro AR. Spinal infection: state of the art and management algorithm. Eur Spine J. 2013;22(12):2787-99. [Crossref]  [PubMed]  [PMC] 
  25. Babic M, Simpfendorfer CS. Infections of the spine. Infect Dis Clin North Am. 2017;31(2):279-97. [Crossref]  [PubMed] 
  26. Dufour V, Feydy A, Rillardon L, Redondo A, Le Page L, Bert F, et al. Comparative study of postoperative and spontaneous pyogenic spondylodiscitis. Semin Arthritis Rheum. 2005;34(5):766-71. [Crossref]  [PubMed] 
  27. Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, et al; Infectious Diseases Society of America. 2015 Infectious Diseases Society of America (IDSA) Clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015;61(6):e26-46. [Crossref]  [PubMed] 
  28. Pola E, Taccari F, Autore G, Giovannenze F, Pambianco V, Cauda R, et al. Multidisciplinary management of pyogenic spondylodiscitis: epidemiological and clinical features, prognostic factors and long-term outcomes in 207 patients. Eur Spine J. 2018;27(Suppl 2):229-36. [Crossref]  [PubMed] 
  29. Akbar M, Lehner B, Doustdar S, Fürstenberg CH, Hemmer S, Bruckner T, et al. Pyogene spondylodiszitis der brust- und lendenwirbelsäule : eine neue klassifikation zur entscheidungsfindung bei der wahl der operativen therapie [Pyogenic spondylodiscitis of the thoracic and lumbar spine : a new classification and guide for surgical decision-making]. Orthopade. 2011;40(7):614-23. German. [Crossref]  [PubMed] 

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