Evaluating the Role of Conservative Therapy in Cervical Spondylodiscitis: Efficacy of Medical Versus Interventional Pain Treatments

Evaluating the Role of Conservative Therapy in Cervical Spondylodiscitis: Efficacy of Medical Versus Interventional Pain Treatments | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating the Role of Conservative Therapy in Cervical Spondylodiscitis: Efficacy of Medical Versus Interventional Pain Treatments Çiğdem Yalçın, Ali Kutta Çelik, Oğuz Kağan Demirtaş This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4817982/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and Objective: Spondylodiscitis is a severe infection of the spinal discs, often leading to significant morbidity and mortality. The cervical spine is a rare site for this condition due to better blood and lymphatic supply. The primary treatment goal is infection control through long-term antibiotherapy, followed by pain and functional restoration via medical, physical, and interventional therapies. Surgery is reserved for cases with progressive neurologic deficits or severe instability. Methods This retrospective study, approved by the Clinical Research Ethics Committee, included patients diagnosed with cervical spondylodiscitis from December 2017 to January 2023. Exclusions were thoracic/lumbar spondylodiscitis, malignancy history, severe deformities, progressive neurologic deficits, or incomplete data. Diagnosis was based on multidisciplinary evaluations, clinical history, physical examination, and various laboratory and imaging tests. Patients were divided into two groups: those receiving interventional pain treatments (Group 1) and those receiving medical pain treatments (Group 2). Results Out of 132 patients, 21 met inclusion criteria. The average age was 58.33 years, with a mean follow-up of 28.80 months. Interventional treatments showed superior pain reduction (NRS: 1.11 vs. 2.33, p = 0.017) and greater improvement in Neck Disability Index (NDI: 76% vs. 56.66%, p = 0.0009) compared to medical treatments. Both groups showed significant improvements in SF-12 scores and disability percentages, with no significant difference in cervical lordosis angles post-treatment. Conclusion Both medical and interventional pain treatments post-antibiotic therapy effectively improve pain, disability, and quality of life in cervical spondylodiscitis patients. Interventional treatments, targeting the pain source, may offer greater benefits. Further prospective studies are necessary to validate these findings and refine treatment approaches. Surgery remains crucial for select patients with specific indications. Spondilodiscitis Pain Manangement Medial Branch Block Trigger Point Injection Figures Figure 1 Figure 2 Introduction Spondylodiscitis is a serious medical condition characterized by infection of the discs in the spine[ 5 , 6 ]. The disease is caused by the invasion of bacterial or fungal agent and can lead to symptoms such as severe pain, fever, instability and neurological deficits. Spondylodiscitis is a highly catastrophic disease and can significantly increase the risk of morbidity and mortality[ 8 ]. The cervical spine is a rare location for spondylodiscitis due to its relatively better blood and lymphatic supply than other spine region[ 17 ]. In the treatment of spondylodiscitis, the primary goal is infection control[ 4 , 16 ]. Therefore, long-term antibiotherapy appropriate to the agent forms the cornerstone of treatment. Afterwards, the aim is to restore pain and functional capacity. This may require medical treatment, physical therapy and interventional pain treatments. Surgery should be preferred only in cases with progressive neurologic deficits and/or severe instability[ 19 ]. Since cervical spondylodiscitis is an extremely rare condition, there is a gap in the literature regarding its management. In this study, we aimed to evaluate the efficacy and safety of conservative treatment without indication for surgery by comparing the outcomes of only medical therapy or interventional pain management in patients with spontane cervical spondylodiscitis. Our hypothesis suggest that interventional pain management such as trigger point injection, facet joint injection may be an effective method to significantly reduce pain and improve quality of life in patients with cervical spondylodiscitis when medical therapy alone is inadequate. Method The study was conducted according to EQUATOR STROBE observational study guideline. After obtaining approval from the Clinical Research Ethics Committee of local board (2023/123), the files of patients diagnosed with vertebral osteomyelitis between December 2017, and January 2023, were retrospectively screened. The center of this study is a tertiary-care state hospital serving approximately 1.8 million people. There is only one other tertiary-care university hospital in the region. After excluding thoracic and lumbar spondylodiscitis cases, cervical osteomyelitis were included in the study. All the patients were older than 18 years, and none had a history of malignancy. Patients with severe deformities, progressive neurological deficits and/or instability were also excluded due to necessity of surgical treatment. Patients who did not follow up regularly and had missing/incomplete data were excluded. Diagnosis: Diagnosis and treatment plans for patients were determined by a multidisciplinary team consisting of infectious disease specialists, radiologists, physical therapists, pain specialists, and neurosurgeons. Following a comprehensive clinical history and physical examination, all patients underwent a series of tests, including complete blood count (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), QuantiFERON TB test, Brucella-specific agglutination tests, standing cervical X-rays, and contrast-enhanced MRI. Post-treatment response was monitored based on clinical improvement, CRP decline and long-term MRI contrast reduction. Additionally, deformity progression was tracked by monitoring the cervical lordosis angle on standing cervical X-rays. Infection treatment Monthly follow-up of the patients was carried out by infectious disease physcian until inflammation was resolved according to a control MRI. Teicoplanin + ciprofloxacin was given for three months in the presence of pyogenic involvement. In brucellosis, streptomycin + rifampicin + doxycycline was given for three weeks; then, streptomycin was stopped and the rifampicin + doxycycline treatment was applied for seven months (total treatment time was eight months). In pyogenic cases, if no clinical or radiological response is obtained at the end of the 2-month treatment and the QuantiFERON test is positive, the treatment is switched to isoniazid + rifampicin + ethambutol + pyrazinamide and this regime continued minimum 6 months. The cervical MRI images of all the patients were interpreted by the same radiologist and CRP response was monitored for infectious disease specialist. Pain and functional treatment After cure was achieved following antibiotherapy, all patients were first referred to the physiotherapy(PT). After physical therapy, patients with persistent pain were informed about medical pain treatment and interventional pain treatments. Patients were divided into two groups as interventional (group 1) and medical (group 2) according to their preferences. Interventional Therapy (Group 1) Trigger point injections are performed into the sternocleidomastoid (SCM) muscle and trapezius muscle. Painful tender points are identified through palpation, and 0.1–0.2 ml of lidocaine is injected using an insulin syringe. Additionally, bilateral medial branch blocks of the facet joints are performed at levels including those above and below the affected level due to spondylodiscitis. The procedure is guided by fluoroscopy, and for each facet joint, a combination of 0.5 ml of bupivacaine and dexamethasone is injected. (Fig. 1) Figure 1: Lateral (A) and Antero-Posterior (B) Fluoroscopic Images of Medial Branch Block of the Facet Joint Medical Therapy (Group 2) For patients unwilling to undergo interventional treatment, duloxetine hydrochloride is initiated at a dose of 30 mg/day and increased to 60 mg/day after one month (Fig. 1). Follow-up Numerical Rating Scale (NRS) of the patients were recorded before treatment (NRS-0), after antibiotic treatment (NRS-1), after PT (NRS-2), and at six months after medical or interventional treatment (NRS-3). Neck Disabilitiy Index (NDI) and SF-12 scores were recorded before and at six months after the procedure. (Table 1). Deformity Monitoring Patients were monitored for the development of kyphosis secondary to spondylodiscitis using standing lateral cervical X-rays. The lordosis angles were measured from the radiographs taken at the time of diagnosis and one year after treatment. The groups were compared in terms of changes in lordosis. Statistical analysis IBM SPSS Statistics v. 22 (IBM SPSS, Turkey) software package was used for the statistical analyses of the data obtained from the research. The Shapiro-Wilk test was conducted to check whether the parameters were normally distributed. Descriptive statistical methods (mean, standard deviation, median and interquartile range, and frequency) were used to present the data. Independent quantitative parameters were compared between the groups using the Mann-Whitney U test. Dependent quantitative parameters were compared between the groups using the Wilcoxon test. The comparison of two independent variables that conformed to a normal distribution was made with Student t-test. P < 0.05 indicated statistical significance in all the analyses. Results Participants A total of 132 patients were diagnosed with spondylodiscitis during the specified period. Of these, 97 were excluded due to involvement of the lumbar and thoracic spine. Four patients were considered unsuitable for study inclusion due to progressive neurological deficit and severe instability, and underwent surgical intervention. Ten patients were excluded due to missing data during follow-up. The remaining 21 patients were included in the study. After antibiotic therapy and physiotherapy, 12 patients preffered for medical treatment, while 9 patients choosed interventional treatment. (Fig. 1) Descriptive Data The average age of the patients was 58.33 ± 10.65 (40–79) years. There were 12 (57.14%) female patients and 9 (42.85%) male patients. The mean follow-up period was 28.80 ± 10.15 (14–54) months. Seven patients(33.33%) had involvement at the C6-7 level, six patients(28.57%) had involvement at the C5-6 level, five patients(23.8%) had involvement at the C4-5 level, and three patients(14.28%) had involvement at the C3-4 level. Two patients (9.52%) had clinical and laboratory signs of Brucellosis and took an eight-month antibiotic therapy regimen.The remaining nineteen patients(90.47%) responded well to the wide-spectrum pyogenic antibiotic therapy. None of the patients has received an anti-tuberculosis regimen in this series. None of the patients has a previous surgical history. Outcome Data Pre-treatment pain score (NRS1) was 8.90 ± 0.76 (8–10), while post-antibiotic therapy pain score (NRS2) was 5.33 ± 1.46 (3–9), post-physical therapy pain score (NRS3) was 5 ± 1.30 (3–7), and final pain score (NRS4) measured 6 months after medical or interventional pain treatment was 1.80 ± 1.07 (0–4). Pairwise comparisons between groups revealed that NRS1 was significantly higher than NRS2 (p < 0.0001 ), there was no significant difference between NRS2 and NRS3 (p = 0.5157), and NRS3 was significantly higher than NRS4 (p < 0.0001) . The mean SF-12 questionnaire score of the patients before treatment was 31.23 ± 2.84 (27–37), while the SF-12 score after medical or interventional pain treatment was 36.61 ± 2.99 (31–42), indicating a significant improvement ( p < 0.0001 ). The pre-treatment Neck Disability Index (NDI) percentage was 41.52 ± 5.12% (33–50), while the post-treatment NDI percentage was 18.09 ± 14.97% (0–52), indicating a significant improvement (p < 0.0001) . At the time of diagnosis, the cervical lordosis angles of the patients were found to be 12.21 ± 12.44 (-10.8–35.3), while the lordosis angle one year after treatment was determined to be 15.75 ± 11.91 (-8.4–38.5). No significant difference was found in the lordosis angles (p = 0.26). Main Results Medical and interventional pain treatment groups showed no significant differences in NRS1, NRS2, and NRS3 scores obtained before treatment, after antibiotic therapy, and after physical therapy (p values were 0.242, 0.522, and 0.833, respectively). The NRS4 score obtained after the application of different treatments between the two groups was found to be superior in the interventional group (1.11 ± 0.92 (0–2)) compared to the medical treatment group (2.33 ± 0.88 (1–4)) (p = 0.017) . Both the medical and interventional pain treatment groups showed significant improvements in SF-12 questionnaire scores before and after treatment ( p = 0.0089, p = 0.0033 ). However, the magnitude of improvement was not significantly different between the two groups (p = 0.35). Both groups also showed significant improvements in Neck Disability Index (NDI) percentages (p values 0.0089 and 0.0024 , respectively). The interventional group demonstrated a greater improvement in NDI (76 ± 9.21% (64–92)) compared to the medical group (56.66 ± 11.19%) ( p = 0.0009 ). No significant difference was observed between the cervical lordosis angles measured at the time of diagnosis and after treatment in both groups. (Table 1) Table 1 Comprasion between groups Interventional Therapy (N = 9) Medical Therapy (n = 12) Mean. ± SD Med. (Min.-Maks.) Mean ± SD p Age 56.22 ± 7.88 53- (45–69) 59.91 ± 12.43 59- (40–79) 0,22 1 SF12 Before Treatment 31.44 ± 3.71 30- (27–37) 31.08 ± 2.15 30- (28–35) 0.94 2 SF12 After Treatment 39.77 ± 1.98 40- (36–42) 37.75 ± 3.38 39- (31–41) 0.16 2 SF12 Change 8.33 ± 2.64 9- (5–13) 6.66 ± 3.44 7- (0–11) 0.35 2 p 3 0.0089 3 0.0033 3 NDI Before Treatment 83.77 ± 8.8 82- (72–98) 82.5 ± 11.57 80- (66–100) 0.77 2 NDI After Treatment 7.77 ± 11.24 2- (0–30) 25.83 ± 12.77 20- (10–52) 0.0049 2 NDI Change 76 ± 9.21 76- (64–92) 56.66 ± 11.19 58- (32–70) 0.0009 2 p 3 0.0089 3 0.0024 3 NRS-1 (Before Treatment) 8.66 ± 0.86 8- (8–10) 9.08 ± 0.66 9- (8–10) 0.242 2 NRS-2 (After Antibiotherapy) 5.44 ± 1.13 5- (4–8) 5.25 ± 1.71 5- (3–9) 0.522 2 NRS-3 (After Physiotherapy) 4.88 ± 1.05 5- (4–7) 5.08 ± 1.50 5- (3–7) 0.833 2 NRS-4 (After Medical/Interventional Therapy) 1.11 ± 0.92 1- (0–2) 2.33 ± 0.88 2- (1–4) 0.017 2 Cervical Lordosis at Diagnosis 14.97 ± 16.59 (-10.8–35.8) 10.14 ± 8.39 (-7–23) 0.27 2 Cervical Lordosis after Treatment (one-year) 13.62 ± 8.68 (-8.4 -24.9) 18.58 ± 15.34 (-7–38.5) 0.37 2 1 Student t-test, 2 Mann Whitney U, 3 Wilcoxon test Discussion While antibiotic therapy remains the cornerstone of treatment for spondylodiscitis, patients often do not experience adequate improvement in their quality of life, pain scores, and disability following this treatment. Therefore, once the infection is controlled, these patients require additional pain management strategies to facilitate rehabilitation and a return to normal life[ 14 ]. This study investigated the effectiveness of interventional or medical treatments following long-term antibiotic therapy for chronic pain, quality of life and disability. The findings suggest that both treatment approaches had a positive impact on quality of life, disability, and pain scores. Specifically, facet joint medial branch block and trigger point injection, which target above and below of affected level, were found to be more effective than medical treatment in reducing pain and disability scores. However, no significant difference was observed between the two treatment modalities in terms of quality of life (SF-12 questionnaire). Interventional treatments focus directly on the source of pain, such as facet joints and trigger points[ 12 , 13 ]. This can provide more localized pain relief compared to systemic medication and limit systemic side effects. In a study conducted on patients presenting to the emergency department due to trigger points, one group received trigger point injections while the other group was given NSAIDs. When comparing VAS scores, it was found that the injections were more effective[ 10 ]. Because the local anesthetic administered to the trigger point blocks peripheral nociceptive input.[ 2 ] Local anti-inflammatory agents may be more effective than systemic treatment, since the main cause of disability and pain in spondylodiscitis is severe inflammation in the affected area[ 9 ]. Inflammatory mediators that cause pain are released from degenerated facet joints. Agents administered directly to the area not only exhibit anti-inflammatory effects but also reduce pain by washing away inflammatory cytokines in the area[ 3 ]{Citation}. A critical predictor of the efficacy of systemic therapies is the reaching of a therapeutic concentration of the drug in the blood. This can delay the onset of pain relief, especially in conditions such as spondylodiscitis associated with acute and severe pain. Local applications can provide faster pain relief than systemic therapies by delivering drugs directly to the source of pain. This may be an important advantage, especially in the treatment of acute pain and in improving patient compliance. This study indicates that the need for surgery in spondylodiscitis is gradually decreasing and the importance of conservative management is growing. This trend can be explained by advances in antibiotic therapy, improved rehabilitation programs and a better understanding of the surgery-related morbidity and mortality. Surgical treatment may be considered a last option in the treatment of spondylodiscitis. In this series, none of the patients who did not require surgical treatment at the time of diagnosis subsequently developed a need for surgery[ 7 , 18 , 20 ]. Specifically, it was observed that none of the patients developed kyphotic deformity in the sagittal balance parameter, and thus, there was no need for surgery related to this condition. In the presence of neurologic deficit, progressive deformity or instability, surgery can be necessary. However, surgical treatment also has significant risks. Implant placement may lead to difficulties in infection control and poor bone quality may be associated to implant failure[ 1 , 11 , 15 ]. In our series, only 4 (11.42%) of 35 patients with cervical spondylodiscitis required surgical treatment. This finding supports the decreasing role of surgical treatment and the importance of conservative management. Considering the cost-effectiveness of conservative treatment, the most appropriate treatment plan for patients should be determined. However, although the need for surgery in overall is decreasing, it is important to realize that surgical intervention is critically important and life-saving for a specific group of patients. In carefully selected cases, such as those with severe neurological deficits or progressive instability, surgery can provide significant therapeutic benefits and improve quality of life. Limitations Due to the rarity of spondylodiscitis in the cervical region, the number of patients included in the study was relatively small. Small samples may limit the power of statistical analyses and the generalizability of findings. Secondly, the study has a retrospective design. Third, the choice of treatment was left to the patients, and although information was provided objectively, the hypothesis that interventional treatment was superior may have led to a bias in the treatment decision. Fourtly microbiological diagnosis was not obtained from all patients. In some patients, treatment was initiated before microbiologic diagnosis based on the adequacy of radiological, clinical, and laboratory findings for diagnosis. The findings obtained in the study need to be supported in future studies with randomized and prospective data. In addition, the effect of advanced local methods such as radiofrequency thermocoagulation and cryo-ablation for facet blockage may be examined. Conclusion This study suggests that both medical and interventional pain treatments following antibiotic therapy can be beneficial for improving pain, disability, and quality of life in patients with cervical spondylodiscitis. Interventional pain management,targeting the source of pain with facet joint injections and trigger point injections, might offer a greater advantage in reducing pain and improving disability compared to medical treatment. However, larger, prospective studies are needed to confirm these findings and explore the role of advanced local methods. While surgery is becoming less frequent due to advancements in conservative management, it remains critically important and potentially life-saving for a select group of patients. Further research is warranted to optimize treatment algorithms that integrate both conservative and surgical approaches for optimal patient outcomes. Declarations Author Contribution ÇY: Draft articleAKÇ: Data collectionOKD: Revise the article, supervision Conflict of Interest and Funding: Authors declare no conflict of interest and study receive no funding Ethical Approval: Ethical board approval was taken by instutional board with number 2023/123 Funding: This study receive no funding and authors declare no conflict of interest References Bettag C, Abboud T, von der Brelie C, Melich P, Rohde V, Schatlo B (2020) Do we underdiagnose osteoporosis in patients with pyogenic spondylodiscitis? 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Dtsch Arztebl Int 105:181–187. doi: 10.3238/arztebl.2008.0181 Waheed G, Soliman MAR, Ali AM, Aly MH (2019) Spontaneous spondylodiscitis: review, incidence, management, and clinical outcome in 44 patients. Neurosurgical Focus 46:E10. doi: 10.3171/2018.10.FOCUS18463 Zarghooni K, Röllinghoff M, Sobottke R, Eysel P (2012) Treatment of spondylodiscitis. International Orthopaedics (SICOT) 36:405–411. doi: 10.1007/s00264-011-1425-1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4817982","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":347298943,"identity":"21e5e42a-f459-44f2-9745-7f2ef597e7e8","order_by":0,"name":"Çiğdem Yalçın","email":"","orcid":"","institution":"Mersin City Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Çiğdem","middleName":"","lastName":"Yalçın","suffix":""},{"id":347298944,"identity":"afd1a80f-eea1-49ae-a852-b3866f5df4df","order_by":1,"name":"Ali Kutta Çelik","email":"","orcid":"","institution":"Mersin City Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"Kutta","lastName":"Çelik","suffix":""},{"id":347298945,"identity":"df905ca3-3681-4d6a-bc48-a76ee959a69e","order_by":2,"name":"Oğuz Kağan Demirtaş","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYDACHjDJDEZAYAPEjI0HiNXC2MDAkAbS0kCkFgawlsNgLl4t/DyHH7/4ucNaTred9/mDH3/O261tPwy0pcYmGpcWyd42M8veM+nGZofZDRt7224nbzuTCNRyLC23AYcWg/MMZga8bYcTtx1mY2zgbbidbHYAqIWx4TAeLezfDP+2Ha4HaWn88+dcstn5hwS0nO0xfgy0JcEMqKWZh+2AndkNArZI9pwpY5ZtSzcE2TJbti05wewG0JYEPH7h50nf/PFtm7W82fljDB/f/LGzNzuf/vDBhxobnFqAgE0CmZcIVpmAWzkIMH9A5tnjVzwKRsEoGAUjEQAA7U9l0HhSKn4AAAAASUVORK5CYII=","orcid":"","institution":"Sincan Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"Oğuz","middleName":"Kağan","lastName":"Demirtaş","suffix":""}],"badges":[],"createdAt":"2024-07-28 19:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4817982/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4817982/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64708223,"identity":"3f4abd78-5193-45dc-9ba0-03802f6e7a79","added_by":"auto","created_at":"2024-09-18 01:38:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":240766,"visible":true,"origin":"","legend":"\u003cp\u003eLateral (A) and Antero-Posterior (B) Fluoroscopic Images of Medial Branch Block of the Facet Joint\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4817982/v1/bbcd197b0dff198ed60549cc.png"},{"id":64708221,"identity":"1b10d164-1a2d-4733-96c6-e7332b5d36e3","added_by":"auto","created_at":"2024-09-18 01:38:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":180752,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 1: Flow Diagram of Study Inclusion and Exclusion Criteria\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4817982/v1/6fb48d6f1836e3ec119ade05.png"},{"id":64710784,"identity":"95dff3ba-cb17-4c2c-bb51-311e910d63a8","added_by":"auto","created_at":"2024-09-18 01:54:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":912514,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4817982/v1/8c1768fe-b679-439b-83a1-0573f5175101.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating the Role of Conservative Therapy in Cervical Spondylodiscitis: Efficacy of Medical Versus Interventional Pain Treatments","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpondylodiscitis is a serious medical condition characterized by infection of the discs in the spine[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The disease is caused by the invasion of bacterial or fungal agent and can lead to symptoms such as severe pain, fever, instability and neurological deficits. Spondylodiscitis is a highly catastrophic disease and can significantly increase the risk of morbidity and mortality[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The cervical spine is a rare location for spondylodiscitis due to its relatively better blood and lymphatic supply than other spine region[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the treatment of spondylodiscitis, the primary goal is infection control[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, long-term antibiotherapy appropriate to the agent forms the cornerstone of treatment. Afterwards, the aim is to restore pain and functional capacity. This may require medical treatment, physical therapy and interventional pain treatments. Surgery should be preferred only in cases with progressive neurologic deficits and/or severe instability[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince cervical spondylodiscitis is an extremely rare condition, there is a gap in the literature regarding its management. In this study, we aimed to evaluate the efficacy and safety of conservative treatment without indication for surgery by comparing the outcomes of only medical therapy or interventional pain management in patients with spontane cervical spondylodiscitis. Our hypothesis suggest that interventional pain management such as trigger point injection, facet joint injection may be an effective method to significantly reduce pain and improve quality of life in patients with cervical spondylodiscitis when medical therapy alone is inadequate.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e The study was conducted according to EQUATOR STROBE observational study guideline. After obtaining approval from the Clinical Research Ethics Committee of local board (2023/123), the files of patients diagnosed with vertebral osteomyelitis between December 2017, and January 2023, were retrospectively screened. The center of this study is a tertiary-care state hospital serving approximately 1.8\u0026nbsp;million people. There is only one other tertiary-care university hospital in the region.\u003c/p\u003e \u003cp\u003eAfter excluding thoracic and lumbar spondylodiscitis cases, cervical osteomyelitis were included in the study. All the patients were older than 18 years, and none had a history of malignancy. Patients with severe deformities, progressive neurological deficits and/or instability were also excluded due to necessity of surgical treatment. Patients who did not follow up regularly and had missing/incomplete data were excluded.\u003c/p\u003e \u003cp\u003eDiagnosis: Diagnosis and treatment plans for patients were determined by a multidisciplinary team consisting of infectious disease specialists, radiologists, physical therapists, pain specialists, and neurosurgeons. Following a comprehensive clinical history and physical examination, all patients underwent a series of tests, including complete blood count (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), QuantiFERON TB test, Brucella-specific agglutination tests, standing cervical X-rays, and contrast-enhanced MRI. Post-treatment response was monitored based on clinical improvement, CRP decline and long-term MRI contrast reduction. Additionally, deformity progression was tracked by monitoring the cervical lordosis angle on standing cervical X-rays.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInfection treatment\u003c/strong\u003e \u003cp\u003eMonthly follow-up of the patients was carried out by infectious disease physcian until inflammation was resolved according to a control MRI. Teicoplanin\u0026thinsp;+\u0026thinsp;ciprofloxacin was given for three months in the presence of pyogenic involvement. In brucellosis, streptomycin\u0026thinsp;+\u0026thinsp;rifampicin\u0026thinsp;+\u0026thinsp;doxycycline was given for three weeks; then, streptomycin was stopped and the rifampicin\u0026thinsp;+\u0026thinsp;doxycycline treatment was applied for seven months (total treatment time was eight months). In pyogenic cases, if no clinical or radiological response is obtained at the end of the 2-month treatment and the QuantiFERON test is positive, the treatment is switched to isoniazid\u0026thinsp;+\u0026thinsp;rifampicin\u0026thinsp;+\u0026thinsp;ethambutol\u0026thinsp;+\u0026thinsp;pyrazinamide and this regime continued minimum 6 months. The cervical MRI images of all the patients were interpreted by the same radiologist and CRP response was monitored for infectious disease specialist.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePain and functional treatment\u003c/strong\u003e \u003cp\u003eAfter cure was achieved following antibiotherapy, all patients were first referred to the physiotherapy(PT). After physical therapy, patients with persistent pain were informed about medical pain treatment and interventional pain treatments. Patients were divided into two groups as interventional (group 1) and medical (group 2) according to their preferences.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInterventional Therapy (Group 1)\u003c/strong\u003e \u003cp\u003eTrigger point injections are performed into the sternocleidomastoid (SCM) muscle and trapezius muscle. Painful tender points are identified through palpation, and 0.1\u0026ndash;0.2 ml of lidocaine is injected using an insulin syringe. Additionally, bilateral medial branch blocks of the facet joints are performed at levels including those above and below the affected level due to spondylodiscitis. The procedure is guided by fluoroscopy, and for each facet joint, a combination of 0.5 ml of bupivacaine and dexamethasone is injected. (Fig.\u0026nbsp;1)\u003c/p\u003e \u003c/p\u003e \u003cp\u003eFigure 1: Lateral (A) and Antero-Posterior (B) Fluoroscopic Images of Medial Branch Block of the Facet Joint\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMedical Therapy (Group 2)\u003c/strong\u003e \u003cp\u003eFor patients unwilling to undergo interventional treatment, duloxetine hydrochloride is initiated at a dose of 30 mg/day and increased to 60 mg/day after one month (Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFollow-up\u003c/strong\u003e \u003cp\u003eNumerical Rating Scale (NRS) of the patients were recorded before treatment (NRS-0), after antibiotic treatment (NRS-1), after PT (NRS-2), and at six months after medical or interventional treatment (NRS-3). Neck Disabilitiy Index (NDI) and SF-12 scores were recorded before and at six months after the procedure. (Table\u0026nbsp;1).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDeformity Monitoring\u003c/strong\u003e \u003cp\u003ePatients were monitored for the development of kyphosis secondary to spondylodiscitis using standing lateral cervical X-rays. The lordosis angles were measured from the radiographs taken at the time of diagnosis and one year after treatment. The groups were compared in terms of changes in lordosis.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIBM SPSS Statistics v. 22 (IBM SPSS, Turkey) software package was used for the statistical analyses of the data obtained from the research. The Shapiro-Wilk test was conducted to check whether the parameters were normally distributed. Descriptive statistical methods (mean, standard deviation, median and interquartile range, and frequency) were used to present the data. Independent quantitative parameters were compared between the groups using the Mann-Whitney U test. Dependent quantitative parameters were compared between the groups using the Wilcoxon test. The comparison of two independent variables that conformed to a normal distribution was made with Student t-test. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated statistical significance in all the analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cstrong\u003eParticipants\u003c/strong\u003e \u003cp\u003eA total of 132 patients were diagnosed with spondylodiscitis during the specified period. Of these, 97 were excluded due to involvement of the lumbar and thoracic spine. Four patients were considered unsuitable for study inclusion due to progressive neurological deficit and severe instability, and underwent surgical intervention. Ten patients were excluded due to missing data during follow-up. The remaining 21 patients were included in the study. After antibiotic therapy and physiotherapy, 12 patients preffered for medical treatment, while 9 patients choosed interventional treatment. (Fig.\u0026nbsp;1)\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDescriptive Data\u003c/strong\u003e \u003cp\u003eThe average age of the patients was 58.33\u0026thinsp;\u0026plusmn;\u0026thinsp;10.65 (40\u0026ndash;79) years. There were 12 (57.14%) female patients and 9 (42.85%) male patients. The mean follow-up period was 28.80\u0026thinsp;\u0026plusmn;\u0026thinsp;10.15 (14\u0026ndash;54) months. Seven patients(33.33%) had involvement at the C6-7 level, six patients(28.57%) had involvement at the C5-6 level, five patients(23.8%) had involvement at the C4-5 level, and three patients(14.28%) had involvement at the C3-4 level. Two patients (9.52%) had clinical and laboratory signs of Brucellosis and took an eight-month antibiotic therapy regimen.The remaining nineteen patients(90.47%) responded well to the wide-spectrum pyogenic antibiotic therapy. None of the patients has received an anti-tuberculosis regimen in this series. None of the patients has a previous surgical history.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOutcome Data\u003c/strong\u003e \u003cp\u003ePre-treatment pain score (NRS1) was 8.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76 (8\u0026ndash;10), while post-antibiotic therapy pain score (NRS2) was 5.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46 (3\u0026ndash;9), post-physical therapy pain score (NRS3) was 5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30 (3\u0026ndash;7), and final pain score (NRS4) measured 6 months after medical or interventional pain treatment was 1.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 (0\u0026ndash;4). Pairwise comparisons between groups revealed that NRS1 was significantly higher than NRS2 \u003cb\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e), there was no significant difference between NRS2 and NRS3 (p\u0026thinsp;=\u0026thinsp;0.5157), and NRS3 was significantly higher than NRS4 \u003cb\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/b\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe mean SF-12 questionnaire score of the patients before treatment was 31.23\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84 (27\u0026ndash;37), while the SF-12 score after medical or interventional pain treatment was 36.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.99 (31\u0026ndash;42), indicating a significant improvement (\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eThe pre-treatment Neck Disability Index (NDI) percentage was 41.52\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12% (33\u0026ndash;50), while the post-treatment NDI percentage was 18.09\u0026thinsp;\u0026plusmn;\u0026thinsp;14.97% (0\u0026ndash;52), indicating a significant improvement \u003cb\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eAt the time of diagnosis, the cervical lordosis angles of the patients were found to be 12.21\u0026thinsp;\u0026plusmn;\u0026thinsp;12.44 (-10.8\u0026ndash;35.3), while the lordosis angle one year after treatment was determined to be 15.75\u0026thinsp;\u0026plusmn;\u0026thinsp;11.91 (-8.4\u0026ndash;38.5). No significant difference was found in the lordosis angles (p\u0026thinsp;=\u0026thinsp;0.26).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMain Results\u003c/strong\u003e \u003cp\u003eMedical and interventional pain treatment groups showed no significant differences in NRS1, NRS2, and NRS3 scores obtained before treatment, after antibiotic therapy, and after physical therapy (p values were 0.242, 0.522, and 0.833, respectively). The NRS4 score obtained after the application of different treatments between the two groups was found to be superior in the interventional group (1.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92 (0\u0026ndash;2)) compared to the medical treatment group (2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88 (1\u0026ndash;4)) \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.017)\u003c/b\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eBoth the medical and interventional pain treatment groups showed significant improvements in SF-12 questionnaire scores before and after treatment (\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.0089, p\u0026thinsp;=\u0026thinsp;0.0033\u003c/b\u003e). However, the magnitude of improvement was not significantly different between the two groups (p\u0026thinsp;=\u0026thinsp;0.35).\u003c/p\u003e \u003cp\u003eBoth groups also showed significant improvements in Neck Disability Index (NDI) percentages (p values \u003cb\u003e0.0089\u003c/b\u003e and \u003cb\u003e0.0024\u003c/b\u003e, respectively). The interventional group demonstrated a greater improvement in NDI (76\u0026thinsp;\u0026plusmn;\u0026thinsp;9.21% (64\u0026ndash;92)) compared to the medical group (56.66\u0026thinsp;\u0026plusmn;\u0026thinsp;11.19%) (\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.0009\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eNo significant difference was observed between the cervical lordosis angles measured at the time of diagnosis and after treatment in both groups. (Table\u0026nbsp;1)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComprasion between groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterventional Therapy (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMedical Therapy (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMean.\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003eSD\u003c/p\u003e \u003cp\u003eMed. (Min.-Maks.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e56.22\u0026thinsp;\u0026plusmn;\u0026thinsp;7.88\u003c/p\u003e \u003cp\u003e53- (45\u0026ndash;69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.91\u0026thinsp;\u0026plusmn;\u0026thinsp;12.43\u003c/p\u003e \u003cp\u003e59- (40\u0026ndash;79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0,22\u003csup\u003e\u003cb\u003e1\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSF12 Before Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e31.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.71\u003c/p\u003e \u003cp\u003e30- (27\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15\u003c/p\u003e \u003cp\u003e30- (28\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0.94\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSF12 After Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e39.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e \u003cp\u003e40- (36\u0026ndash;42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.38\u003c/p\u003e \u003cp\u003e39- (31\u0026ndash;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0.16\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSF12 Change\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e8.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64\u003c/p\u003e \u003cp\u003e9- (5\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.66\u0026thinsp;\u0026plusmn;\u0026thinsp;3.44\u003c/p\u003e \u003cp\u003e7- (0\u0026ndash;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0.35\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.0089\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0033\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNDI Before Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e83.77\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003cp\u003e82- (72\u0026ndash;98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.57\u003c/p\u003e \u003cp\u003e80- (66\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0.77\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNDI After Treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7.77\u0026thinsp;\u0026plusmn;\u0026thinsp;11.24\u003c/p\u003e \u003cp\u003e2- (0\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e25.83\u0026thinsp;\u0026plusmn;\u0026thinsp;12.77\u003c/p\u003e \u003cp\u003e20- (10\u0026ndash;52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.0049\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNDI Change\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e76\u0026thinsp;\u0026plusmn;\u0026thinsp;9.21\u003c/p\u003e \u003cp\u003e76- (64\u0026ndash;92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e56.66\u0026thinsp;\u0026plusmn;\u0026thinsp;11.19\u003c/p\u003e \u003cp\u003e58- (32\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.0009\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.0089\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.0024\u003c/b\u003e\u003csup\u003e\u003cb\u003e3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNRS-1 (Before Treatment)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e8.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003cp\u003e8- (8\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e9.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003cp\u003e9- (8\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.242\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNRS-2 (After Antibiotherapy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003cp\u003e5- (4\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71\u003c/p\u003e \u003cp\u003e5- (3\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.522\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNRS-3 (After Physiotherapy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e \u003cp\u003e5- (4\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003cp\u003e5- (3\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.833\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNRS-4 (After Medical/Interventional Therapy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003cp\u003e1- (0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e \u003cp\u003e2- (1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCervical Lordosis at Diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e14.97\u0026thinsp;\u0026plusmn;\u0026thinsp;16.59 (-10.8\u0026ndash;35.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e10.14\u0026thinsp;\u0026plusmn;\u0026thinsp;8.39 (-7\u0026ndash;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.27\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCervical Lordosis after Treatment (one-year)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e13.62\u0026thinsp;\u0026plusmn;\u0026thinsp;8.68 (-8.4 -24.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e18.58\u0026thinsp;\u0026plusmn;\u0026thinsp;15.34 (-7\u0026ndash;38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.37\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e1\u003c/sup\u003eStudent t-test, \u003csup\u003e2\u003c/sup\u003eMann Whitney U, \u003csup\u003e3\u003c/sup\u003eWilcoxon test\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile antibiotic therapy remains the cornerstone of treatment for spondylodiscitis, patients often do not experience adequate improvement in their quality of life, pain scores, and disability following this treatment. Therefore, once the infection is controlled, these patients require additional pain management strategies to facilitate rehabilitation and a return to normal life[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This study investigated the effectiveness of interventional or medical treatments following long-term antibiotic therapy for chronic pain, quality of life and disability. The findings suggest that both treatment approaches had a positive impact on quality of life, disability, and pain scores.\u003c/p\u003e \u003cp\u003eSpecifically, facet joint medial branch block and trigger point injection, which target above and below of affected level, were found to be more effective than medical treatment in reducing pain and disability scores. However, no significant difference was observed between the two treatment modalities in terms of quality of life (SF-12 questionnaire). Interventional treatments focus directly on the source of pain, such as facet joints and trigger points[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This can provide more localized pain relief compared to systemic medication and limit systemic side effects. In a study conducted on patients presenting to the emergency department due to trigger points, one group received trigger point injections while the other group was given NSAIDs. When comparing VAS scores, it was found that the injections were more effective[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Because the local anesthetic administered to the trigger point blocks peripheral nociceptive input.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Local anti-inflammatory agents may be more effective than systemic treatment, since the main cause of disability and pain in spondylodiscitis is severe inflammation in the affected area[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Inflammatory mediators that cause pain are released from degenerated facet joints. Agents administered directly to the area not only exhibit anti-inflammatory effects but also reduce pain by washing away inflammatory cytokines in the area[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]{Citation}. A critical predictor of the efficacy of systemic therapies is the reaching of a therapeutic concentration of the drug in the blood. This can delay the onset of pain relief, especially in conditions such as spondylodiscitis associated with acute and severe pain. Local applications can provide faster pain relief than systemic therapies by delivering drugs directly to the source of pain. This may be an important advantage, especially in the treatment of acute pain and in improving patient compliance.\u003c/p\u003e \u003cp\u003eThis study indicates that the need for surgery in spondylodiscitis is gradually decreasing and the importance of conservative management is growing. This trend can be explained by advances in antibiotic therapy, improved rehabilitation programs and a better understanding of the surgery-related morbidity and mortality. Surgical treatment may be considered a last option in the treatment of spondylodiscitis. In this series, none of the patients who did not require surgical treatment at the time of diagnosis subsequently developed a need for surgery[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Specifically, it was observed that none of the patients developed kyphotic deformity in the sagittal balance parameter, and thus, there was no need for surgery related to this condition. In the presence of neurologic deficit, progressive deformity or instability, surgery can be necessary. However, surgical treatment also has significant risks. Implant placement may lead to difficulties in infection control and poor bone quality may be associated to implant failure[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our series, only 4 (11.42%) of 35 patients with cervical spondylodiscitis required surgical treatment. This finding supports the decreasing role of surgical treatment and the importance of conservative management. Considering the cost-effectiveness of conservative treatment, the most appropriate treatment plan for patients should be determined. However, although the need for surgery in overall is decreasing, it is important to realize that surgical intervention is critically important and life-saving for a specific group of patients. In carefully selected cases, such as those with severe neurological deficits or progressive instability, surgery can provide significant therapeutic benefits and improve quality of life.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLimitations\u003c/strong\u003e \u003cp\u003eDue to the rarity of spondylodiscitis in the cervical region, the number of patients included in the study was relatively small. Small samples may limit the power of statistical analyses and the generalizability of findings. Secondly, the study has a retrospective design. Third, the choice of treatment was left to the patients, and although information was provided objectively, the hypothesis that interventional treatment was superior may have led to a bias in the treatment decision. Fourtly microbiological diagnosis was not obtained from all patients. In some patients, treatment was initiated before microbiologic diagnosis based on the adequacy of radiological, clinical, and laboratory findings for diagnosis.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe findings obtained in the study need to be supported in future studies with randomized and prospective data. In addition, the effect of advanced local methods such as radiofrequency thermocoagulation and cryo-ablation for facet blockage may be examined.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study suggests that both medical and interventional pain treatments following antibiotic therapy can be beneficial for improving pain, disability, and quality of life in patients with cervical spondylodiscitis. Interventional pain management,targeting the source of pain with facet joint injections and trigger point injections, might offer a greater advantage in reducing pain and improving disability compared to medical treatment. However, larger, prospective studies are needed to confirm these findings and explore the role of advanced local methods. While surgery is becoming less frequent due to advancements in conservative management, it remains critically important and potentially life-saving for a select group of patients. Further research is warranted to optimize treatment algorithms that integrate both conservative and surgical approaches for optimal patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e\u0026Ccedil;Y: Draft articleAK\u0026Ccedil;: Data collectionOKD: Revise the article, supervision\u003c/p\u003e\u003cp\u003eConflict of Interest and Funding: Authors declare no conflict of interest and study receive no funding\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical Approval:\u0026nbsp;\u003c/em\u003eEthical board approval was taken by instutional board with number\u0026nbsp;2023/123\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003eThis study receive no funding and authors declare no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBettag C, Abboud T, von der Brelie C, Melich P, Rohde V, Schatlo B (2020) Do we underdiagnose osteoporosis in patients with pyogenic spondylodiscitis? Neurosurg Focus 49:E16. doi: 10.3171/2020.5.FOCUS20267\u003c/li\u003e\n\u003cli\u003eBorg-Stein J, Stein J (1996) Trigger points and tender points: one and the same? Does injection treatment help? Rheum Dis Clin North Am 22:305\u0026ndash;322. doi: 10.1016/s0889-857x(05)70274-x\u003c/li\u003e\n\u003cli\u003eDu R, Xu G, Bai X, Li Z (2022) Facet Joint Syndrome: Pathophysiology, Diagnosis, and Treatment. J Pain Res 15:3689\u0026ndash;3710. doi: 10.2147/JPR.S389602\u003c/li\u003e\n\u003cli\u003eFransen BL, de Visser E, Lenting A, Rodenburg G, van Zwet AA, Gisolf EH (2014) Recommendations for diagnosis and treatment of spondylodiscitis. Neth J Med 72:135\u0026ndash;138\u003c/li\u003e\n\u003cli\u003eGentile L, Benazzo F, De Rosa F, Boriani S, Dallagiacoma G, Franceschetti G, Gaeta M, Cuzzocrea F (2019) A systematic review: characteristics, complications and treatment of spondylodiscitis. European Review for Medical and Pharmacological Sciences 23:117\u0026ndash;128. doi: 10.26355/eurrev_201904_17481\u003c/li\u003e\n\u003cli\u003eGhobrial GM, Franco D, Theofanis T, Margiotta PJ, Andrews E, Wilson JR, Harrop JS, Heller JE (2017) Cervical Spondylodiscitis: Presentation, Timing, and Surgical Management in 59 Patients. World Neurosurgery 103:664\u0026ndash;670. doi: 10.1016/j.wneu.2017.04.119\u003c/li\u003e\n\u003cli\u003eHeyde CE, Boehm H, El Saghir H, Tsch\u0026ouml;ke SK, Kayser R (2006) Surgical treatment of spondylodiscitis in the cervical spine: a minimum 2-year follow-up. Eur Spine J 15:1380\u0026ndash;1387. doi: 10.1007/s00586-006-0191-z\u003c/li\u003e\n\u003cli\u003eKehrer M, Pedersen C, Jensen TG, Hallas J, Lassen AT (2015) Increased short- and long-term mortality among patients with infectious spondylodiscitis compared with a reference population. The Spine Journal 15:1233\u0026ndash;1240. doi: 10.1016/j.spinee.2015.02.021\u003c/li\u003e\n\u003cli\u003eKnezevic NN, Jovanovic F, Voronov D, Candido KD (2018) Do Corticosteroids Still Have a Place in the Treatment of Chronic Pain? Front Pharmacol 9:1229. doi: 10.3389/fphar.2018.01229\u003c/li\u003e\n\u003cli\u003eKocak AO, Ahiskalioglu A, Sengun E, Gur STA, Akbas I (2019) Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: A prospective randomized study. Am J Emerg Med 37:1927\u0026ndash;1931. doi: 10.1016/j.ajem.2019.01.015\u003c/li\u003e\n\u003cli\u003eLang S, Rupp M, Hanses F, Neumann C, Loibl M, Alt V (2021) [Infections of the spine : Pyogenic spondylodiscitis and implant-associated vertebral osteomyelitis]. Unfallchirurg 124:489\u0026ndash;504. doi: 10.1007/s00113-021-01002-w\u003c/li\u003e\n\u003cli\u003eManchikanti L, Kaye A, Soin A, Albers S, Beall D, Latchaw R, Sanapati M, Shah S, Atluri S, Abd-Elsayed A, Abdi S, Aydin S, Bakshi S, Boswell M, Buenaventura R, Cabaret J, Calodney A, Candido K, Christo P, Cintron L, Diwan S, Gharibo C, Grider J, Gupta M, Haney B, Harned M, Helm S, Jameson J, Jha S, Kaye A, Knezevic N (2020) Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American society of interventional pain physicians (asipp) guidelines. Pain Physician 23:S1\u0026ndash;S127\u003c/li\u003e\n\u003cli\u003eManchikanti L, Kosanovic R, Pampati V, Sanapati MR, Hirsch JA (2022) Outcomes of Cervical Therapeutic Medial Branch Blocks and Radiofrequency Neurotomy: Clinical Outcomes and Cost Utility are Equivalent. Pain Physician\u003c/li\u003e\n\u003cli\u003eMavrogenis AF, Megaloikonomos PD, Igoumenou VG, Panagopoulos GN, Giannitsioti E, Papadopoulos A, Papagelopoulos PJ (2017) Spondylodiscitis revisited. EFORT Open Rev 2:447\u0026ndash;461. doi: 10.1302/2058-5241.2.160062\u003c/li\u003e\n\u003cli\u003eMotov S, Stemmer B, Krauss P, Bonk M-N, Wolfert C, Steininger K, Sommer B, Shiban E (2023) Implant selection in cervical spondylodiscitis plays a non-detrimental role - a single-center retrospective case series of 24 patients [Abstract]. doi: 10/1-s2.0-S2772529423003806-main.pdf\u003c/li\u003e\n\u003cli\u003eRutges JPHJ, Kempen DH, van Dijk M, Oner FC (2016) Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review. Eur Spine J 25:983\u0026ndash;999. doi: 10.1007/s00586-015-4318-y\u003c/li\u003e\n\u003cli\u003eShousha M, Boehm H (2012) Surgical Treatment of Cervical Spondylodiscitis: A Review of 30 Consecutive Patients. Spine 37:E30. doi: 10.1097/BRS.0b013e31821bfdb2\u003c/li\u003e\n\u003cli\u003eSobottke R, Seifert H, F\u0026auml;tkenheuer G, Schmidt M, Go\u0026szlig;mann A, Eysel P (2008) Current Diagnosis and Treatment of Spondylodiscitis. Dtsch Arztebl Int 105:181\u0026ndash;187. doi: 10.3238/arztebl.2008.0181\u003c/li\u003e\n\u003cli\u003eWaheed G, Soliman MAR, Ali AM, Aly MH (2019) Spontaneous spondylodiscitis: review, incidence, management, and clinical outcome in 44 patients. Neurosurgical Focus 46:E10. doi: 10.3171/2018.10.FOCUS18463\u003c/li\u003e\n\u003cli\u003eZarghooni K, R\u0026ouml;llinghoff M, Sobottke R, Eysel P (2012) Treatment of spondylodiscitis. International Orthopaedics (SICOT) 36:405\u0026ndash;411. doi: 10.1007/s00264-011-1425-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spondilodiscitis, Pain Manangement, Medial Branch Block, Trigger Point Injection","lastPublishedDoi":"10.21203/rs.3.rs-4817982/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4817982/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Objective:\u003c/h2\u003e \u003cp\u003eSpondylodiscitis is a severe infection of the spinal discs, often leading to significant morbidity and mortality. The cervical spine is a rare site for this condition due to better blood and lymphatic supply. The primary treatment goal is infection control through long-term antibiotherapy, followed by pain and functional restoration via medical, physical, and interventional therapies. Surgery is reserved for cases with progressive neurologic deficits or severe instability.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study, approved by the Clinical Research Ethics Committee, included patients diagnosed with cervical spondylodiscitis from December 2017 to January 2023. Exclusions were thoracic/lumbar spondylodiscitis, malignancy history, severe deformities, progressive neurologic deficits, or incomplete data. Diagnosis was based on multidisciplinary evaluations, clinical history, physical examination, and various laboratory and imaging tests. Patients were divided into two groups: those receiving interventional pain treatments (Group 1) and those receiving medical pain treatments (Group 2).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of 132 patients, 21 met inclusion criteria. The average age was 58.33 years, with a mean follow-up of 28.80 months. Interventional treatments showed superior pain reduction (NRS: 1.11 vs. 2.33, p\u0026thinsp;=\u0026thinsp;0.017) and greater improvement in Neck Disability Index (NDI: 76% vs. 56.66%, p\u0026thinsp;=\u0026thinsp;0.0009) compared to medical treatments. Both groups showed significant improvements in SF-12 scores and disability percentages, with no significant difference in cervical lordosis angles post-treatment.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBoth medical and interventional pain treatments post-antibiotic therapy effectively improve pain, disability, and quality of life in cervical spondylodiscitis patients. Interventional treatments, targeting the pain source, may offer greater benefits. Further prospective studies are necessary to validate these findings and refine treatment approaches. Surgery remains crucial for select patients with specific indications.\u003c/p\u003e","manuscriptTitle":"Evaluating the Role of Conservative Therapy in Cervical Spondylodiscitis: Efficacy of Medical Versus Interventional Pain Treatments","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-18 01:37:57","doi":"10.21203/rs.3.rs-4817982/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"30f96a2e-dca4-407b-9b32-e68d1de90bd3","owner":[],"postedDate":"September 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-18T01:38:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-18 01:37:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4817982","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4817982","identity":"rs-4817982","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}