International Orthopaedics (SICOT) (2012) 36:405–411

DOI 10.1007/s00264-011-1425-1

REVIEW ARTICLE

Treatment of spondylodiscitis
Kourosh Zarghooni & Marc Röllinghoff & Rolf Sobottke &
Peer Eysel

Received: 10 October 2011 / Accepted: 9 November 2011 / Published online: 6 December 2011
# Springer-Verlag 2011

Abstract Overall the quality of life seems to be more favourable in

Purpose Pyogenic infections of the spine are relatively rare patients following surgical treatment of spondylodiscitis.
with an incidence between 1:100,000 and 1:250,000 per year, Conclusion With close clinical and radiological monitoring
but the incidence is increasing due to increases in average life- of patients with spondylodiscitis, conservative and surgical
expectancy, risk factors, and medical comorbidities. The mean therapies have become more successful. When indicated,
time in hospital varies from 30 to 57 days and the hospital surgical stabilisation of the infected segments is mandatory
mortality is reported to be 2–17%. This article presents the for control of the disease and immediate mobilisation of the
relevant literature and our experience of conservative and patients.
surgical treatment of pyogenic spondylodiscitis.
Method We have performed a review of the relevant literature
and report the results of our own research in the diagnosis and Introduction
treatment of pyogenic spondylodiscitis. We present a sequen-
tial algorithm for identification of the pathogen with blood Spondylodiscitis is uncommon and, because initial signs
cultures, CT-guided biopsies and intraoperative tissue sam- and symptoms are nonspecific in nature, a delay before
ples. Basic treatment principles and indications for surgery diagnosis and treatment often occurs. In the literature, the
and our surgical strategies are discussed. average duration between the first symptoms and diagnosis
Results Recent efforts have been directed toward early has been reported to be between two and six months [1–8].
mobilisation of patients using primary stable surgical The term “spondylodiscitis” refers to the primary
techniques that lead to a further reduction of the mortality. infection of the intervertebral disc by a pathogen and
Currently our hospital mortality in patients with spondylo- secondary osteomyelitis of the adjacent end-plates, usually
discitis is around 2%. With modern surgical and antibiotic occurring in conjunction with one another. The incidence of
treatment, a relapse of spondylodiscitis is unlikely to occur. spondylodiscitis varies in developed countries between
In literature the relapse rate of 0–7% has been recorded. 1:100,000 and 1:250,000 [1, 2, 9–11]. It is the main
manifestation of haematogenous osteomyelitis in patients
aged over 50 years and represents around 3–5% of all cases
K. Zarghooni (*) of osteomyelitis [12].
Department of Orthopaedic and Trauma Surgery,
In this article we will discuss conservative and surgical
ZKS (BMBF 01KN1106), University of Cologne,
Cologne, Germany treatment and outcomes of pyogenic spondylodiscitis, based
e-mail: kourosh.zarghooni@uk-koeln.de on a review of the literature and our own research experience.

M. Röllinghoff : R. Sobottke : P. Eysel

Department of Orthopaedic and Trauma Surgery,
University of Cologne, General management of spondylodiscitis
Cologne, Germany
The principles of treatment are eradication of the underlying
M. Röllinghoff
infection, restoration and preservation of spinal structure and
Department of Orthopaedic and Trauma Surgery,
Martin Luther University Halle-Wittenberg, stability, recovery from any neurological deficits, and appro-
Halle, Germany priate pain therapy.
406 International Orthopaedics (SICOT) (2012) 36:405–411

Immobilisation or fixation of the affected spine seg- switch from parenteral to oral administration of anti-
ments, antibiotic therapy, and, depending on the extent of biotics can be performed earlier, as soon as the patient’s
the disease, debridement and decompression of the spinal general condition has been reliably stabilised and the
canal are basic requirements for successful treatment serum inflammatory markers have returned to normal or
yielding complete recovery from spondylodiscitis [12]. at least significantly improved [12]. The transfer to oral
Heterogeneity of the patient population as well as administration can also take place sooner if enteral
variations in treatment complicates the establishment of bioavailability of the active ingredient is high, e.g. as is
standard therapeutic guidelines. To date, there have been no the case with fluoroquinolones, clindamycin, or linezolid.
randomised controlled trials to guide selection of the Linezolid is mainly used in cases of MRSA infection,
appropriate route, duration, and agents for antibiotic although one should be aware of the haematopoietic side
therapy [13]. The level of evidence for treatment recom- effects [6, 18, 19].
mendations does not exceed level C [14]. Consistent recommendations concerning the overall
Microbiological diagnosis is essential to enable targeted duration of antibiotic therapy are also lacking in the
antibiotic treatment. Agent-sensitive intravenous antibiotics literature. With regard to the treatment of nonspecific
should be begun preferably only once the pathogen has spondylodiscitis, antibiotic administration from six weeks
been identified and a table of resistance/sensitivity has been to three months has been suggested [1, 5, 10, 20, 21]. In
formulated. Specimens for microbial studies should be any case, the duration of treatment depends on the
taken from the port of entry and at least three sets of blood condition of the individual patient. If in doubt, high-risk
cultures should be collected at different times after patients (e.g. those with immunosuppression, diabetes
discontinuation of antipyretic and antibiotic agents. If the mellitus, drug abuse) in particular should be treated for
patient requires urgent treatment due to sepsis or a longer. It is our practice to administer antibiotic therapy
fulminant disease course, empirical therapy with a broad- until inflammatory parameters have remained within the
spectrum antibiotic regimen appropriate to treat the most normal range for six consecutive weeks.
common pathogens for spondylodiscitis, i.e. Staphylococ- If, however, the historical, clinical, and radiological data
cus aureus and Escherichia coli, should be initiated only suggest tuberculous spondylodiscitis, appropriate therapeu-
after collecting blood cultures [12]. Based on our experience, tic agents may be initiated. Usually these cases are not
we suggest the following algorithm for collection of blood fulminant, so that the microbiological findings can be
cultures, CT-guided biopsy, and intraoperative sampling awaited. Based on experience and retrospective data,
(Fig. 1) [12, 15]. antituberculous therapy should be continued for at least
The literature offers no standardised guidelines as to the 18–24 months to allow for complete healing and prevent
duration of intravenous antibiotic treatment. As a general relapse [12]. Atypical mycobacteria pose a serious thera-
rule, it is advisable to administer antibiotics intravenously peutic problem because of frequent resistance [22, 23]. A
for at least two to four weeks to improve bioavailability. definitive therapeutic regime for the treatment of atypical
Observational studies have yielded a higher incidence of mycobacteria has not yet been established. The guidelines of
treatment failure when parenteral therapy was administered the American Thoracic Society, dating from 1997, recom-
for less than four weeks [16, 17]. In individual cases, the mend combination therapy of isoniazid, rifampicin, and
Fig. 1 Algorithm for the
diagnosis and treatment of Minimum of 3 Blood Cultures (BC)
spondylodiscitis
No Surgery Surgery

BC negative or Pathogen BC positive and Pathogen BC negative or Pathogen

not plausible plausible not plausible:
Empirical Therapy
No therapy, CT-guided Biopsy negative or pathogen
biopsy not plausible
Biopsy negative or
Biopsy positive and Biopsy positive and Pathogen not
Pathogen plausible Pathogen plausible plausible

Targeted antibiotic Therapy Empirical antibiotic Therapy

International Orthopaedics (SICOT) (2012) 36:405–411 407

ethambutol, with or without streptomycin or clarithromycin, six weeks if no radiological evidence of reactive bony
for the treatment of pulmonary infections [24]. fusion is present, if destruction has progressed, or if clinical
If a mycotic infection has been verified, adequate improvement has not occurred [3, 7, 30]. Thus, we
antimycotic therapy must be initiated. Spondylodiscitis advocate bed rest until pain symptoms are controlled, but
caused by fungi can closely resemble tuberculous spondy- generally no longer than two weeks, with subsequent
lodiscitis on magnetic resonance imaging [25]. Overall, it is mobilisation in an orthesis.
difficult to identify fungi as a cause for spondylodiscitis, Within the context of conservative treatment, paraverte-
and antimycotic therapy is often complicated. Thus, van bral abscess formations requiring decompression can be
Ooij et al. advocate surgical treatment at an early stage of treated by CT-guided drain insertion and drainage until
the disease [26]. resorption has been documented by CT-imaging.

Conservative treatment Surgical treatment

In the absence of an absolute indication for surgery, when Urgent surgical intervention for spondylodiscitis is required
clinical symptoms are mild or bony destruction is minimal, when either neurological deficits or sepsis develop. Further
and/or the risks of surgical intervention seem too high, a indications for surgery are listed in Table 1. Relative
conservative approach may be considered [3, 7, 12]. With indications for surgical treatment include uncontrollable
the surgical risks in mind, conservative therapy often is the pain symptoms and lack of patient compliance with
primary option for elderly patients and for patients in poor conservative therapy [2, 9, 12, 21]. The goals of surgery
general condition [27]. are debridement and removal of the septic focus, collec-
Spinal immobilisation is a very important aspect of tion of specimens for microbiological testing and histo-
treatment, and often presents a challenge in conservative pathological examination, decompression of the spinal
therapy. Adequate immobilisation of the affected segments canal, with stabilisation and restoration of the infected
obviates the need for prolonged bed rest. For the cervical spine segment, and subsequent bony fusion. In compari-
spine, immobilisation can be achieved using a collar or son to conservative therapy, this approach allows for a
halo-fixator. For the mid-thoracic spine, a reclining brace safer and more rapid cure of the inflammation. Also,
can suffice. This orthesis holds the affected spine segments mobilisation can be begun shortly after surgery [3, 12, 30].
in a reclining position, distributing weight to the generally Since the mid-1950s, when Hodgson et al. published their
unaffected facet joints, and reducing stress on the diseased articles on the treatment of tuberculous spondylodiscitis of
vertebra. Even when the thoracolumbar or lumbar region is the whole spine, anterior debridement with interbody bone
involved, and destruction is not too severe, mobilisation in grafting became the gold standard therapy, and remained
a thoracolumbar or lumbosacral orthosis can be considered so until the 1990s [31]. However, anterior spinal fusion
[12]. However, bed rest for a period of at least six weeks is with bone graft alone does not result in primary stability. It
still required for substantial defects of the anterior column necessitates several weeks of patient immobilisation
as well as disease affecting the lower lumbar or lumbosacral followed by several months of brace treatment before
segments [3, 12]. firm bony union with the graft can be achieved [3]. In
In a retrospective case series analysis, for patients contrast to conservative therapy, the fusion rate increased
lacking indications for surgical therapy, Flamme et al. to 90–100% [3, 32]. In cases with multi-segmental
recommended conservative therapy with consistent immo-
bilisation of the patient in a reclining plaster shell for Table 1 Indications for surgery in spondylodiscitis
six weeks, followed by another six weeks of brace
Indications for surgery in spondylodiscitis
treatment . The plaster shell generated a kyphotic position,
and thus achieved fast pain relief [28]. When considering 1. Neurological deficits
the treatment of the elderly in particular, one must also 2. Sepsis
recognise the well-known morbidity related to bed rest, e.g. 3. Significant bone involvement with instability
decubitus ulceration, deep vein thrombosis, pulmonary 4. Impending or current deformities
embolism, and pneumonia. 5. Intraspinal space-occupying processes (i.e. spinal abscess)
In addition to the risks of bed rest, the rates of 6. Unclear aetiology of the process and/or suspected malignant disease
pseudarthrosis and instability, which can both ultimately 7. Failure to respond to conservative therapy
result in kyphotic deformation and chronic pain syndromes, 8. Uncontrollable pain
are comparatively high at 16–50% [2, 3, 10, 28, 29]. 9. Patient's lack of compliance
Conservative therapy should not be continued past four to
408 International Orthopaedics (SICOT) (2012) 36:405–411

involvement and longer fusion spans, however, there are favoured if the patient’s general health is reduced. The
higher rates of complications such as pseudarthrosis and second stage is performed one to two weeks after the first,
bone graft displacement with subsequent kyphotic defor- depending on the patient’s recovery.
mation [3]. Thus, instrumented stabilisation in conjunction Recommendations regarding the choice of interior
with debridement and graft interposition has been established stabilisation are equally diverse; suggested approaches
as the current standard procedure. This enables rapid include purely posterior stabilisation, anterior only, com-
postoperative mobilisation of the patient and reduces the risks bined posterior-anterior, or combined anterior-posterior stabi-
of pseudarthrosis and kyphotic deformation [2, 3, 12]. lisation [2, 3, 5, 7, 10, 21, 29, 36, 37].
The intact posterior elements of the affected spine Table 2 presents our current treatment concept of
segment should not be destabilised by decompression pyogenic spondylodiscitis which is based on the grade of
laminectomy alone, as this may result in further instability destruction of the affected segments. In our experience the
and potential deterioration of the neurological situation [2, grade of segmental destruction, the necessity for debridement,
5, 16, 33, 34]. the segmental kyphosis and the intraspinal extent of the
Of course, implantation of fixation materials into an disease are pivotal for the further treatment. Patients with
infected site bears the risks of pathogenic colonisation and severe destruction or multisegmental disease may need several
persistent infection. Spinal instrumentation can be applied revisions in sequence for debridement and stabilisation.
successfully, however, if thorough debridement of the In the cervical spine (Fig. 2), an anterior approach can be
infected bone and wound area is provided with concomitant performed including adequate debridement and stabilisation
application of local antibiotic agents [10, 12]. Thorough with structural autologous bone graft (i.e. iliac crest) or a
debridement down to the vital, well-perfused spongy bone fusion cage filled with autologous trabecular bone graft,
is essential to enable complete cure of the infection [3, 11, along with anterior plate insertion. Locking plate systems
29]. In common with most spine surgeons we advocate the may also be implemented, especially when more than one
use of titanium implants, as they do not seem to be spine segment is diseased (Fig. 3) [5]. Bi- or poly-
associated with increased recurrence rates [4, 35]. segmental infections may require posterior-anterior stabili-
Recommendations regarding the optimal surgical strategy sation. Postoperatively, the patient should wear a semi-rigid
for spondylodiscitis remain controversial [1, 2, 4, 5, 7, 10, 21, cervical collar for four to six weeks [38].
36, 37]. This is most likely due to patient heterogeneity and When the thoracic spine is affected, a single-step
variation in therapeutic methods. Surgical therapy for posterior approach may suffice even when there is
spondylodiscitis can be performed as either one-stage or significant destruction of the anterior column. Stability is
two-stage surgery. When neurological deficits are present, generally maintained by the rib cage, and mobility is
urgent decompression plus stabilisation should be performed, restricted physiologically [39, 40]. However, anterior
because the prognosis of neurological sequelae depends on instrumentation alone may also be sufficient. Anterior
swift surgical intervention [7]. In patients lacking neurolog- stabilisation of the spine can be achieved either by open
ical symptoms, a two-stage surgical procedure may be transthoracic or open posterolateral approach, or via

Table 2 Conservative and

surgical treatment of pyogenic Segment Grade of destruction
spondylodiscitis. All implants
used should be titanium. In very Low Moderate Severe
severe spondylodiscitis multiple
revisions and debridements Cervical spine 1. Cervical brace 1. Anterior 1. Titanium fusion cage with
might be indicated 2. Anterior autologous iliac autologous iliac autologous cancellous bone
bone graft and (locking) plate bone graft and 2. If very severe: Additional
(locking) plate posterior screw-rod-system
Thoracic spine 1. Posterior stabilisation with 1. Thoracoscopic 1. Transthoracic with
percutaneous screw-rod- (up to L2) with autologous iliac bone graft;
system (minimal invasive iliac autologous if multisegmental with rib/
spine surgery; MISS) bone graft and fibula and plate
plate 2. If very severe: Additional
posterior screw-rod-system
Thoracolumbar 1. Reclining rigid brace 1. Posterior lumbar 1. 1- or 2-step 360° fusion
and lumbar (usually polyethylene) interbody fusion with anterior iliac bone
spine 2. Posterior stabilisation with (PLIF) with graft; if multisegmental
percutaneous screw-rod- titanium cage with fibula and posterior
system (MISS) screw-rod-system
International Orthopaedics (SICOT) (2012) 36:405–411 409

Fig. 2 a T1-weighted sagittal

image without gadolinium
shows decreased signal intensity
from the C3 and C4 vertebrae
and an epidural collection
extending from C2 to the
mid-aspect of C5. b
T1-weighted sagittal image after
gadolinium shows significant
enhancement of the epidural
space at C2–C7 levels and the
anterior soft tissues C2-C6.
c T2-weighted sagittal image
shows increased signal intensity
from C3 and C4 vertebrae,
associated with increased signal
from the intervertebral disc C3/4
and evidence of an epidural
collection C3-C6

thoracoscopy. The advantages of the minimally-invasive

thoracoscopic approach are reduced postoperative pain,
improved shoulder function, improved postoperative lung
function, earlier patient mobilisation, decreased tissue
trauma from the approach, better cosmetic results, and
shorter hospitalisation time [41]. By splitting the dia-
phragm, the thoracoscopic approach can be extended
inferiorly as far as L2 [41]. In monosegmental defects,
fusion can be achieved by interposition of a structural
autologous bone graft (i.e. tri-cortical bone graft). In multi-
segmental disease, an autologous fibula or rib graft could
also be used. In case of insufficient anterior stability,
supplemental posterior stabilisation should be performed
[3].
In the thoracolumbar and lumbar spine, if anterior
debridement is not urgently required, posterior stabilisation
should be performed initially. In cases of minimal destruc-
tion anteriorly, or where sufficient stability is provided by
Fig. 3 Postoperative anteroposterior (a) and lateral (b) radiographs
posterior instrumentation and there is increased surgical risk, it
after discectomy and debridement of C3/4 and C4/5 and anterior might be better to suspend two-stage anterior instrumentation
fixation with locking plate C3-C5 with bone graft interposition. After stabilisation and while
410 International Orthopaedics (SICOT) (2012) 36:405–411

receiving antibiotic therapy, spontaneous healing of the anterior stabilisation. The anterior substance defect was
infected focus with fusion of the adjacent vertebrae can occur bridged using bone graft interposition in 42 cases, and
over the postoperative course [2]. In cases of monosegmental titanium cage in 20 cases. Segmental correction loss after
spondylodiscitis with minor kyphosis, anterior fusion with cage insertion was significantly lower than that after bone
bone graft alone might be considered [3]. By using anterior graft interposition (1° vs. 4.1°). In all cases, bony fusion
stable locking implants, sufficient stabilisation can be was achieved [4].
achieved [21, 29]. Lee et al. published a retrospective series
of 18 patients with spondylodiscitis and slight bony
destruction, treated with autologous iliac crest bone graft Prognosis
using the PLIF (posterior lumbar interbody fusion) technique
[37]. The advantage of a single anterior or posterior approach Spondylodiscitis is potentially life-threatening because it is
compared to a combined strategy lies in the lower grade of often not recognised at an early stage. Moreover, it
invasiveness and decreased blood loss, although anterior primarily affects elderly patients in reduced states of health
instrumentation especially at the lumbar spine or lumbosacral or with the accompanying risk factors mentioned above.
junction levels carries increased risks of injuring the large Mean hospital stay has been reported as 30–49 days, and
abdominal or pelvic vessels that are often adherent due to hospital mortality as 2–17% [2, 7, 21, 36, 43]. With our
inflammation [2]. In a prospective randomised study, own patients, mean hospital stay is four weeks with a
Linhardt et al. compared long-term clinical and radiological hospital mortality of 2%.
outcomes after anterior-posterior versus solely anteriorly In a retrospective study, Woertgen et al. researched
instrumented thoracic and lumbar fusions performed on 22 neurological results and quality of life (SF-36) for 62
patients with spondylodiscitis [21]. For both methods, a spondylodiscitis patients after 16.4 months. Of these
fusion rate of 100% was reached. The mean sagittal loss of patients, 45% had been treated conservatively and 55%
correction was 2° for anterior-posterior fusion, 4° for a surgically. For patients with neurological deficits present
purely anterior fusion at the thoracic level, and 3° for anterior prior to surgery, motor deficits persisted in 30%, and
fusion alone at the lumbar level. Analysis of the SF-36, hypaesthesia in 90%. In addition, quality of life for all
Oswestry low-back pain disability questionnaire, and visual patients was far lower than that of a normal population.
pain scales showed significantly better results after anterior Slightly improved quality of life and significantly higher
stabilisation alone for the follow-up periods of two years and levels of patient satisfaction were found in the surgically-
5.4 years after surgery. Similar findings were reported by treated patients [43]. In a group of 25 spondylodiscitis
our group comparing primary stable anterior instrumen- patients, Lerner et al. identified an improvement of
tation (n=23) with posterior-anterior spinal fusion (n= neurological deficits for 76% after a mean of 2.6 years,
32). While both groups featured the same correction loss while 20% showed no change. In 75% of patients with
of 2.8°, the time of operation was 50% longer, and there acute paraplegia, ambulation was restored after therapy [4].
was a 50% increase in blood loss for the patients treated Similar results can be found in other published studies [2, 3,
with posterior-anterior fusion versus the control group. 38]. Overall, a relapse of spondylodiscitis is unlikely to
Bony fusion was achieved in all patients [30]. Known occur. In the literature, relapse rates have been recorded as
complications of the anterior approach, apart from 0–7% [2, 3, 21, 29, 38, 41].
bleeding, are neurological complications, injury of the
internal organs, intestines and ureter, and adhesion
formation [2, 29, 30].
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