Surgical Management of Spondylodiscitis: A Single-Center Retrospective Analysis of 126 Cases

Surgical Management of Spondylodiscitis: A Single-Center Retrospective Analysis of 126 Cases | 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 Surgical Management of Spondylodiscitis: A Single-Center Retrospective Analysis of 126 Cases Pavel Trávníček, Lenka Ryšková, Tomáš Hosszú, Roman Kostyšyn, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8005034/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 Introduction/background: Pyogenic spondylodiscitis is a serious spinal infection. Surgical debridement with or without stabilization is an established adjunct to antibiotic therapy, yet indication criteria and operative extent vary across the literature. We evaluated outcomes of surgically treated spondylodiscitis at our institution (2015–2024). Methods We retrospectively analyzed consecutive patients indicated for surgery. Variables included procedure type (decompression alone vs. instrumentation), presence of epidural abscess, reoperation for relapse or new-onset instability, microbiology, length of hospital stay (LOS), early outcomes, and admission clinical status. Results We identified 126 patients (87 men, 69%); mean age 65 years (range 13–91). Surgery was performed in 108 patients: decompression alone in 76 (70.4%), instrumented decompression in 21 (19.4%), standalone instrumentation in 4 (3.7%), and multistage combined procedures in 7 (6.5%). An epidural abscess was present at the index operation in 98/108 (90.7%), confirmed intraoperatively or on preoperative MRI. Disease relapse occurred in 23.1%; reoperation for progressive instability in 15.7%. The most common pathogen was Staphylococcus aureus (55%), followed by streptococci (11%) and Enterobacterales (14%). Mean LOS was 35.3 days (median 27). Multiorgan failure developed in 44 patients (35%). Seven patients died. No implant-related complications were observed. Conclusions In most operated cases, early surgical source control with decompression without instrumentation was sufficient. When instability is demonstrated, instrumentation is safe even in active infection provided meticulous debridement and targeted antibiotic therapy are employed. The high diagnostic yield of blood cultures and tissue samples supports early acquisition and repetition as needed. spondylodiscitis spondylitis epidural abscess magnetic resonance imaging antibiotic therapy instrumentation spine intervertebral disc 1. Introduction Infectious spondylodiscitis is a serious spinal infection involving the intervertebral disc and/or the adjacent vertebral bodies. It is an inherently multidisciplinary condition that engages multiple medical and surgical specialties. The incidence has been rising in recent decades, driven by population aging, a higher burden of comorbidities, and improved detection owing to broad availability of sensitive imaging modalities—particularly magnetic resonance imaging (MRI) with gadolinium-based contrast [ 1 – 3 ]. Randomized controlled trials of antimicrobial therapy are lacking, and there is currently no national consensus guideline for diagnosis and treatment in the Czech Republic [ 1 ]. Pathogenesis is most commonly hematogenous. In adults, infection typically begins in the subchondral regions of the vertebral bodies with secondary spread to the intervertebral disc; in children it may more rarely start in the disc due to different vascularization [ 2 , 3 ]. Infection can extend into the paravertebral compartments and the epidural space with abscess formation; less commonly it involves the subdural space or the central nervous system (CNS) (meningitis, myelitis) [ 4 ]. Microbiologically, Staphylococcus aureus predominates (up to ~ 60%), followed by Enterobacterales and other cocci; mycobacterial, fungal, and parasitic etiologies are less frequent but clinically important (e.g., Mycobacterium tuberculosis) [ 3 – 5 ]. In epidural abscesses, S. aureus and streptococci prevail [ 6 ]. The most common location is the lumbar spine (≈ 58%), followed by thoracic (≈ 30%) and cervical (≈ 11%); multisegment involvement is uncommon and more often associated with atypical pathogens [ 6 , 7 ]. Risk factors include diabetes mellitus, intravenous drug use, catheter-related infections, recent spinal surgery, infective endocarditis, urinary tract infection, chronic alcoholism, and conditions associated with immunosuppression [ 8 ]. In complicated courses (e.g., subdural abscess), liver cirrhosis and chronic renal failure have also been reported [ 5 ]. The disease shows two age peaks: a pediatric form (especially 2–8 years) and an adult form peaking in the 5th–7th decades; males are more frequently affected (ratio ~ 1.5–2:1) [ 1 , 2 ]. Clinical manifestations are nonspecific. Localized back or neck pain—often nocturnal and at rest—predominates; radicular radiation is common and may lead to misdiagnosis. Fever is absent in a substantial proportion of patients. Neurological deficit is present in approximately one third of cases and more commonly accompanies delayed diagnosis, epidural abscess, cervical involvement, or tuberculous etiology; the spectrum ranges from sensorimotor deficits and radiculopathy to paraplegia or conus/cauda syndromes with sphincter dysfunction [ 3 , 5 ]. Diagnosis relies on contrast-enhanced MRI and laboratory testing including repeated blood cultures and inflammatory markers. Early, high-quality microbiological confirmation is crucial for targeted therapy; prematurely initiated empirical antibiotic therapy markedly reduces culture yield and increases the risk of relapse [ 3 , 7 ]. In uncomplicated cases, the standard approach is conservative management with immobilization and at least six weeks of antimicrobial therapy; percutaneous abscess drainage may be appropriate for early collections [ 1 ]. Surgical treatment is indicated for instability, progressive or impending neurological deficit, failure of conservative therapy, extensive epidural/paravertebral abscess, or diagnostic uncertainty; the goals are eradication of the infectious focus, decompression of neural elements, and restoration of spinal stability [ 1 – 4 ]. The aim of this single-center retrospective study is to describe the indication criteria, the scope of surgical procedures, and early outcomes—including complications—in spondylodiscitis managed at the authors’ institution. 2. Materials and Methods Single-center retrospective observational study conducted at the authors’ institution in 2015–2024. Consecutive hospitalized patients with spondylodiscitis who were indicated for conservative or surgical management at our center were included. The diagnosis was based on the clinical picture (localized back/neck pain, fever, neurological deficit, signs of sepsis) and contrast-enhanced MRI of the affected spinal segment [ 9 ]; plain radiography was added as needed. Data were systematically extracted from the medical record. The following were recorded: demographics, comorbidities, and body-mass index (BMI) (with emphasis on diabetes mellitus and long-term corticosteroid therapy); clinical presentation at admission (pain, fever, neurological deficit, sepsis) and the Medical Research Council (MRC) muscle strength score (0–5); inflammatory and organ-function laboratory indices (complete blood count, C-reactive protein [CRP]; as indicated, procalcitonin, urea, creatinine, estimated glomerular filtration rate); microbiology (see below); imaging findings (contrast-enhanced MRI; plain radiography); treatment strategy (conservative vs. surgical), timing, and surgical approach/procedure type; hospitalization metrics and discharge status (pain at discharge categorized as none/improved/unchanged/worsened) and the need for reoperation. MRI was obtained in all potentially operable patients. Blood cultures were drawn at admission whenever feasible prior to antibiotic initiation. Tissue sampling from the spinal focus was performed in all patients: intraoperatively in those operated on, or via CT-guided biopsy in non-operative/deferred cases. The primary diagnostic modality was culture of material obtained intraoperatively or by biopsy; in culture-negative cases with concomitantly negative blood cultures, polymerase chain reaction (PCR) was added. The presence of an epidural abscess was recorded. Conservative therapy comprised immobilization with an orthosis and targeted antibiotic therapy based on blood cultures or CT-guided biopsy results; empiric antibiotics were initiated only in patients presenting with sepsis, according to local recommendations. Surgical treatment was categorized by extent into: debridement and decompression without instrumentation, instrumented decompression, instrumentation alone (without decompression), staged/combined procedures. The surgical approach (anterior/posterior/combined) and intraoperative findings, including epidural abscess, were recorded. Timing categories were mutually exclusive and referred to the index operation: primary (early), delayed after antibiotic therapy and clinical stabilization, or after failure of conservative therapy. Primary outcomes : presence of a drainable (pus-containing) epidural abscess, defined by intraoperative purulence or preoperative MRI features of a fluid collection with rim enhancement and diffusion restriction; reoperation for relapse/residual infection; development or progression of spinal instability - an increase in the kyphotic angle of ≥ 10° or > 50% vertebral body height loss. Secondary outcomes : length of hospital stay and in-hospital mortality; pain status at discharge (none/improved/unchanged/worsened); diagnostic yield of microbiology (blood cultures, tissue cultures, PCR). A descriptive analysis was performed: categorical variables are presented as counts and percentages; continuous variables as mean (standard deviation [SD]) and/or median (interquartile range [IQR]) according to distribution. The study had no prespecified inferential hypothesis; analyses focused on describing treatment strategies and early outcomes. Statistical processing was performed using NCSS (NCSS, LLC, East Kaysville, Utah, USA; version NCSS 2025, www.ncss.com ). 3. Results A total of 126 patients with spondylodiscitis were included (men 69%, women 31%); mean age 65 years (range 13–91). Baseline characteristics are summarized in Table 1 . Table 1 Baseline cohort characteristics and laboratory indices. Variable Value Number of patients, n 126 Age, mean (range), years 65 (13–91) Sex, n (%) Men 87 (69%) Women 39 (31%) BMI 1 , mean (min–max) 29.15 (17.60–52.20) Clinical presentation at admission, n (%) Isolated pain 55 (43.6%); Isolated neurological deficit 16 (12.7%); Sepsis 16 (12.7%); Combination of symptoms 39 (31%) Fever at admission, n (%) 22 (17.5%) MRC 2 score at admission—distribution, n (%) 5: 60 (47.6%); 4: 18 (14.3%); 3: 22 (17.5%); 2: 11 (8.7%); 1: 5 (4%); 0: 10 (7.9%) MRC score - summary Mean 3.69; median 4 Comorbidities / risk factors, n (%) Type 2 diabetes mellitus 53 (42.1%); long-term corticosteroid therapy 41 (32.5%); tobacco use 24 (19%); chronic alcohol misuse 10 (7.9%); intravenous drug use 3 (2.4%) Length of hospital stay, mean (days) 35.3 (median 27) 1 BMI = body-mass index; 2 MRC = Medical Research Council muscle strength score The cohort consisted predominantly of older patients (mean age 65 years) with a substantial comorbidity burden (type 2 diabetes 42.1%, long-term corticosteroid therapy 32.5%). Clinically, back/neck pain predominated; fever was present in only 17.5%, underscoring the nonspecific presentation. The MRC distribution indicates that 52.4% of patients had a motor deficit, reflecting marked functional impairment at admission. MRI was performed in all patients. Distribution by spinal segment: cervical 12%, thoracic 20.6%, lumbar 46%; multilevel disease 21.4%. A pre-existing extra-spinal infectious focus was identified in 68 patients, while isolated spinal involvement without another primary focus was present in 58 patients. Admission blood cultures were obtained in 103/126 patients; 89/103 (86.4%) were positive, corresponding to 89/126 (70.6%) of the entire cohort. Material from the spinal focus was obtained in all patients (intraoperatively in those undergoing surgery, CT-guided biopsy in non-operative/deferred cases). Tissue cultures were positive in 114/126, negative in 11/126, and contaminated/indeterminate in 1/126; PCR was performed in 10 culture-negative samples. The total number of patients with any microbiological confirmation (blood and/or tissue culture and/or PCR) was 121/126 (96.0%). The most frequently identified pathogen was Staphylococcus aureus (85/121, 70.3%), followed by Enterobacterales (18/121, 14.9%; most commonly Escherichia coli, Klebsiella pneumoniae, Salmonella Enteritidis ) and streptococci (16/121, 13.2%). Primary conservative therapy (antibiotics plus orthosis) was selected for 18/126 patients; it was successful in 14/18. Owing to failure of conservative management, 4 of these patients subsequently underwent surgery; an additional 17 patients were referred for surgery after failure of conservative treatment at referring hospitals (total 21 operated after failed conservative care). Primary early surgery was indicated in 74/126 patients: a delayed procedure after antibiotics in 17/126. Surgical management is summarized in Table 2 . Table 2 Surgical management of spondylodiscitis (N = 108). Values are n (% of operated patients). Timing categories are mutually exclusive and refer to the index operation. n % Timing of surgery Primary (early) procedure 74 58.7 Delayed procedure after antibiotics 17 13.5 After failure of conservative therapy* 17 15.7 Number of stages Single-stage procedure 85 78.7 Multistage procedure 23 21.3 Type of surgical procedure Debridement + decompression without instrumentation 76 70.4 Instrumented decompression 21 19.4 Instrumentation alone (no decompression) 4 3.7 Combined multistage procedures 7 6.5 Surgical approach Posterior 90 83.3 Anterior 12 11.1 Combined (anterior + posterior / lateral + posterior) 6 5.6 Lateral alone 0 0.0 Note: 4 patients failed conservative therapy at our center and were subsequently operated; 13 patients were referred for surgery after failure of conservative treatment at referring institutions (total 17). Early surgical intervention and a single-stage strategy predominated. Debridement with decompression without instrumentation was the most common procedure; instrumented procedures represented a minority. The posterior approach was dominant; a pure lateral approach was not used. The high prevalence of epidural abscesses at presentation reflects the severity of cases treated at a tertiary center and explains the predominance of decompressive procedures. Targeted antibiotic therapy was guided by culture results; when the pathogen was unknown, empiric therapy was used in severe septic presentations according to local microbiology. The duration of antibiotic treatment could not be reliably retrieved in many cases and is therefore not reported. Treatment course and outcomes are summarized in Table 3 . Table 3 Treatment outcomes in our spondylodiscitis cohort Cohort N = 126; survivors at discharge n = 119. Domain Outcome n % In-hospital course Multiorgan failure 44 35.0 In-hospital mortality 7 5.6 Discharge disposition (of all 126) Home 26 20.6 Further inpatient/rehabilitation care 93 73.8 Died in hospital 7 5.6 — of which (subset of “Further care”) Direct transfer to a rehabilitation institute¹ 10 — Relapse (of all 126) Disease relapse after treatment 29 23.0 **Pain at discharge (of survivors, n = 119)**² None 12 9.5 Improved 90 71.4 Unchanged 17 13.5 Worsened 0 0.0 Implant-related complications³ Complications related to spinal instrumentation 0 0.0 ¹ Subset of the “Further inpatient/rehabilitation care” group. ² Pain assessed among survivors only (n = 119). Percentages are calculated out of 119. ³Assessed among instrumented cases (denominator detailed in Table 2 ); no implant-related complications were observed. During hospitalization, multiorgan failure occurred in 35% and in-hospital mortality was 5.6%. Most patients were discharged to subsequent inpatient/rehabilitation care (73.8%), with 7.9% transferred directly to a rehabilitation institute. Relapse was documented in nearly one quarter of the cohort. Pain relief at discharge was achieved in the vast majority (80.9% with no pain or improved pain), and we observed no complications related to spinal instrumentation. 4. Discussion In this single-center retrospective cohort of 126 patients with spondylodiscitis, surgical treatment was indicated in 108/126 (85.7%), reflecting the neurosurgical setting—patients not primarily requiring surgery are typically admitted to internal medicine wards. A definitive single-stage approach predominated (85/108, 78.7%). The most frequent procedure was surgical debridement with decompression without instrumentation (76/108, 70.4%). Instrumented procedures accounted for 32/108 (29.6%), of which stand-alone stabilization without canal decompression represented 4/108 (3.7%). We recorded no instrumentation-related mechanical failures. An epidural abscess was present in 98/108 (90.7%) of operated cases, confirmed intraoperatively or on preoperative MRI, explaining both the predominance of decompressive procedures and the dominant posterior approach (90/108, 83.3%). Microbiological verification was high: tissue cultures from the focus were positive in 114/126 (90.5%); blood cultures were positive in 89/103 (86.4%) of those obtained (89/126, 70.6% of the entire cohort). The most common pathogen was Staphylococcus aureus (85/121, 70.3% of cases with confirmed etiology). Clinical outcomes mirror the severity of the cohort (multiorgan failure 44/126, 35.0%; in-hospital mortality 7/126, 5.6%); nevertheless, most patients were discharged with reduced or no pain (96/119 survivors, 80.9%), and relapse occurred in 29/126 (23.0%). Primary conservative management was chosen in 18/126 (14.3%) and was successful in 14/18; failure of conservative therapy necessitated surgery in 21 patients (including referrals). Published reviews and observational studies indicate that conservative treatment is effective in a subset of patients [ 1 , 10 – 12 ], yet surgical indications remain heterogeneous and often lack clear algorithms [ 1 , 10 – 14 ]. Our data add nuance: with early surgical indication in the presence of an epidural abscess, threatened or manifest instability, progressive neurological deficit, or antibiotic failure, debridement and decompression without instrumentation often suffice; instrumentation appears safe when instability is demonstrated, including in florid infection—provided meticulous debridement and targeted antimicrobial therapy are employed. The high diagnostic yield of tissue sampling and blood cultures underscores the value of early, high-quality sampling before or immediately after initiation of therapy. Antibiotic duration is not reported here due to incomplete ascertainment; recommended courses are typically 6–8 weeks [ 15 ]. A definitive consensus on optimal duration and the frequency of follow-up MRI is lacking [ 1 , 10 – 13 , 16 , 17 ]. The high prevalence of epidural abscesses and functional burden at admission (mRC skewed toward lower scores) reflects selection of more severe cases referred to our center. The predominance of posterior approaches aligns with the need for urgent decompression; combined and anterior procedures were reserved for anatomically or biomechanically demanding situations. The absence of implant-related complications in our cohort supports the use of instrumentation when instability criteria are met, while not implying that instrumentation is universally required. Limitations include: (i) retrospective design without a control group and without inferential analyses, limiting causal inference and exposing the data to selection and information bias; (ii) single-center setting, which may limit generalizability; (iii) incomplete capture of the entire conservatively treated population across specialties, as spondylodiscitis is multidisciplinary and many patients are treated outside neurosurgery; (iv) imperfect post-discharge follow-up across multiple post-acute facilities, limiting precise ascertainment of antibiotic start/stop dates (intravenous and oral) and late complications/relapses; (v) absence of standardized cross-disciplinary protocols for follow-up imaging, potentially introducing heterogeneity in indications for re-intervention; and (vi) antibiotic duration (IV and oral) was not analyzed due to incomplete documentation and inter-facility variation in prescribing, precluding adjustment for antimicrobial exposure in outcome comparisons. Our findings support a pragmatic algorithm: early microbiological sampling; early decompression and debridement in epidural abscess or neurological deficit; and instrumentation when instability is confirmed, without an observed increase in implant-related complications in our series. Prospective multicenter studies should aim to: (i) standardize surgical indication criteria; (ii) optimize IV/PO antibiotic duration and the role of early switch to oral therapy; (iii) define follow-up MRI protocols, particularly in the post-operative and post-antibiotic periods; and (iv) validate predictors of relapse. 5. Conclusions Conservative therapy remains the standard for uncomplicated spondylodiscitis, with targeted—often prolonged—antimicrobial treatment as a cornerstone. Staphylococcus aureus predominates microbiologically; early blood cultures and sampling from the spinal focus are therefore essential, with repeat sampling advisable when negative or etiology remains unclear. Surgical indications include, in particular, diagnostic tissue sampling, neurological deficit or its progression, failure of conservative therapy, epidural abscess, and instability or extensive disease. In our cohort, early surgical source control with decompression without instrumentation sufficed in most cases; instrumentation was effective and safe when instability was demonstrated, and we observed no implant-related complications. Meticulous debridement and subsequent targeted antimicrobial therapy are key to success. CT-guided sampling proved a useful adjunct to establish etiology and guide therapy in unclear or non-operative cases. Declarations Ethics approval and consent to participate: The Ethical Committee of the University Hospital Hradec Kralove, Hradec Kralove, Czech Republic (Chairperson Jiri Vortel, MD) determined that this retrospective chart review was exempt from full review and that written informed consent was not required due to the use of de-identified data. The study adhered to the Declaration of Helsinki and applicable data-protection regulations. All data were de-identified prior to analysis; no direct patient identifiers were collected (GDPR-compliant). Consent for publication. Not applicable (no individual person’s data are included). Competing interests. The authors declare no competing interests. Conflicts of Interest: The authors certify that there are no conflicts of interest with any financial organization regarding the materials discussed in this manuscript. Funding: This research was supported by MH CZ – DRO (UHHK, 00179906), this research received no external funding. There was no financial interest in the outcomes from the institution; this is institutional support for research. Author Contribution Conceptualization, P.T. and L.R.; methodology, P.T., L.R. software, M.C..; validation, L.R.; formal analysis, L.R., T.H., T.Č.; investigation, P.T., R.K., T.H., P.R. L.R., J.T.; re-sources, P.T.; data curation – M.C..; writing—original draft preparation, P.T.; writing—review and editing, M.C., T.Č., L.R.; supervision, T.Č., T.H., L.R.; project administration, P.T., M.C.; funding acquisition, P.T. All authors have read and agreed to the published version of the manuscript. All authors participated in critical revision of the manuscript, contributed comments, and approved the final version. Data Availability The study protocol and de-identified dataset supporting the findings are available from the corresponding author upon reasonable request. References Lee KY (2014) Comparison of pyogenic spondylitis and tuberculous spondylitis. Asian Spine J 8(2):216–223 Lang S, Walter N, Heidemanns S (2024) [18F]FDG PET/CT Imaging Is Associated with Lower In-Hospital Mortality in Patients with Pyogenic Spondylodiscitis—A Registry-Based Analysis of 29,362 Cases. 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Int Orthop 36:413–420 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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10:05:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":656911,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8005034/v1/e187c4f1-e72a-40f7-a25f-48435c171948.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Management of Spondylodiscitis: A Single-Center Retrospective Analysis of 126 Cases","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eInfectious spondylodiscitis is a serious spinal infection involving the intervertebral disc and/or the adjacent vertebral bodies. It is an inherently multidisciplinary condition that engages multiple medical and surgical specialties. The incidence has been rising in recent decades, driven by population aging, a higher burden of comorbidities, and improved detection owing to broad availability of sensitive imaging modalities\u0026mdash;particularly magnetic resonance imaging (MRI) with gadolinium-based contrast [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Randomized controlled trials of antimicrobial therapy are lacking, and there is currently no national consensus guideline for diagnosis and treatment in the Czech Republic [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePathogenesis is most commonly hematogenous. In adults, infection typically begins in the subchondral regions of the vertebral bodies with secondary spread to the intervertebral disc; in children it may more rarely start in the disc due to different vascularization [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Infection can extend into the paravertebral compartments and the epidural space with abscess formation; less commonly it involves the subdural space or the central nervous system (CNS) (meningitis, myelitis) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Microbiologically, Staphylococcus aureus predominates (up to ~\u0026thinsp;60%), followed by Enterobacterales and other cocci; mycobacterial, fungal, and parasitic etiologies are less frequent but clinically important (e.g., Mycobacterium tuberculosis) [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In epidural abscesses, S. aureus and streptococci prevail [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The most common location is the lumbar spine (\u0026asymp;\u0026thinsp;58%), followed by thoracic (\u0026asymp;\u0026thinsp;30%) and cervical (\u0026asymp;\u0026thinsp;11%); multisegment involvement is uncommon and more often associated with atypical pathogens [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRisk factors include diabetes mellitus, intravenous drug use, catheter-related infections, recent spinal surgery, infective endocarditis, urinary tract infection, chronic alcoholism, and conditions associated with immunosuppression [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In complicated courses (e.g., subdural abscess), liver cirrhosis and chronic renal failure have also been reported [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The disease shows two age peaks: a pediatric form (especially 2\u0026ndash;8 years) and an adult form peaking in the 5th\u0026ndash;7th decades; males are more frequently affected (ratio\u0026thinsp;~\u0026thinsp;1.5\u0026ndash;2:1) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eClinical manifestations are nonspecific. Localized back or neck pain\u0026mdash;often nocturnal and at rest\u0026mdash;predominates; radicular radiation is common and may lead to misdiagnosis. Fever is absent in a substantial proportion of patients. Neurological deficit is present in approximately one third of cases and more commonly accompanies delayed diagnosis, epidural abscess, cervical involvement, or tuberculous etiology; the spectrum ranges from sensorimotor deficits and radiculopathy to paraplegia or conus/cauda syndromes with sphincter dysfunction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDiagnosis relies on contrast-enhanced MRI and laboratory testing including repeated blood cultures and inflammatory markers. Early, high-quality microbiological confirmation is crucial for targeted therapy; prematurely initiated empirical antibiotic therapy markedly reduces culture yield and increases the risk of relapse [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In uncomplicated cases, the standard approach is conservative management with immobilization and at least six weeks of antimicrobial therapy; percutaneous abscess drainage may be appropriate for early collections [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Surgical treatment is indicated for instability, progressive or impending neurological deficit, failure of conservative therapy, extensive epidural/paravertebral abscess, or diagnostic uncertainty; the goals are eradication of the infectious focus, decompression of neural elements, and restoration of spinal stability [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe aim of this single-center retrospective study is to describe the indication criteria, the scope of surgical procedures, and early outcomes\u0026mdash;including complications\u0026mdash;in spondylodiscitis managed at the authors\u0026rsquo; institution.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eSingle-center retrospective observational study conducted at the authors\u0026rsquo; institution in 2015\u0026ndash;2024. Consecutive hospitalized patients with spondylodiscitis who were indicated for conservative or surgical management at our center were included. The diagnosis was based on the clinical picture (localized back/neck pain, fever, neurological deficit, signs of sepsis) and contrast-enhanced MRI of the affected spinal segment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; plain radiography was added as needed. Data were systematically extracted from the medical record. The following were recorded:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003edemographics, comorbidities, and body-mass index (BMI) (with emphasis on diabetes mellitus and long-term corticosteroid therapy);\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eclinical presentation at admission (pain, fever, neurological deficit, sepsis) and the Medical Research Council (MRC) muscle strength score (0\u0026ndash;5);\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003einflammatory and organ-function laboratory indices (complete blood count, C-reactive protein [CRP]; as indicated, procalcitonin, urea, creatinine, estimated glomerular filtration rate);\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003emicrobiology (see below); imaging findings (contrast-enhanced MRI; plain radiography);\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003etreatment strategy (conservative vs. surgical), timing, and surgical approach/procedure type;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ehospitalization metrics and discharge status (pain at discharge categorized as none/improved/unchanged/worsened) and the need for reoperation.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eMRI was obtained in all potentially operable patients. Blood cultures were drawn at admission whenever feasible prior to antibiotic initiation. Tissue sampling from the spinal focus was performed in all patients: intraoperatively in those operated on, or via CT-guided biopsy in non-operative/deferred cases. The primary diagnostic modality was culture of material obtained intraoperatively or by biopsy; in culture-negative cases with concomitantly negative blood cultures, polymerase chain reaction (PCR) was added. The presence of an epidural abscess was recorded. Conservative therapy comprised immobilization with an orthosis and targeted antibiotic therapy based on blood cultures or CT-guided biopsy results; empiric antibiotics were initiated only in patients presenting with sepsis, according to local recommendations.\u003c/p\u003e\u003cp\u003eSurgical treatment was categorized by extent into:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003edebridement and decompression without instrumentation,\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003einstrumented decompression,\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003einstrumentation alone (without decompression),\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003estaged/combined procedures.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe surgical approach (anterior/posterior/combined) and intraoperative findings, including epidural abscess, were recorded. Timing categories were mutually exclusive and referred to the index operation: primary (early), delayed after antibiotic therapy and clinical stabilization, or after failure of conservative therapy.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrimary outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003epresence of a drainable (pus-containing) epidural abscess, defined by intraoperative purulence or preoperative MRI features of a fluid collection with rim enhancement and diffusion restriction;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ereoperation for relapse/residual infection;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003edevelopment or progression of spinal instability - an increase in the kyphotic angle of \u0026ge;\u0026thinsp;10\u0026deg; or \u0026gt;\u0026thinsp;50% vertebral body height loss.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSecondary outcomes\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003elength of hospital stay and in-hospital mortality;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003epain status at discharge (none/improved/unchanged/worsened);\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ediagnostic yield of microbiology (blood cultures, tissue cultures, PCR).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eA descriptive analysis was performed: categorical variables are presented as counts and percentages; continuous variables as mean (standard deviation [SD]) and/or median (interquartile range [IQR]) according to distribution. The study had no prespecified inferential hypothesis; analyses focused on describing treatment strategies and early outcomes. Statistical processing was performed using NCSS (NCSS, LLC, East Kaysville, Utah, USA; version NCSS 2025, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.ncss.com\" target=\"_blank\"\u003ewww.ncss.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.ncss.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 126 patients with spondylodiscitis were included (men 69%, women 31%); mean age 65 years (range 13\u0026ndash;91). Baseline characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\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\u003eBaseline cohort characteristics and laboratory indices.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of patients, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e126\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, mean (range), years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65 (13\u0026ndash;91)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMen \u003cb\u003e87\u003c/b\u003e (69%)\u003c/p\u003e\u003cp\u003eWomen \u003cb\u003e39\u003c/b\u003e (31%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003csup\u003e1\u003c/sup\u003e, mean (min\u0026ndash;max)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e29.15\u003c/b\u003e (17.60\u0026ndash;52.20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical presentation at admission, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIsolated pain \u003cb\u003e55\u003c/b\u003e (43.6%);\u003c/p\u003e\u003cp\u003eIsolated neurological deficit \u003cb\u003e16\u003c/b\u003e (12.7%);\u003c/p\u003e\u003cp\u003eSepsis \u003cb\u003e16\u003c/b\u003e (12.7%);\u003c/p\u003e\u003cp\u003eCombination of symptoms \u003cb\u003e39\u003c/b\u003e (31%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFever at admission, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e22\u003c/b\u003e (17.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMRC\u003csup\u003e2\u003c/sup\u003e score at admission\u0026mdash;distribution, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5: \u003cb\u003e60\u003c/b\u003e (47.6%);\u003c/p\u003e\u003cp\u003e4: \u003cb\u003e18\u003c/b\u003e (14.3%);\u003c/p\u003e\u003cp\u003e3: \u003cb\u003e22\u003c/b\u003e (17.5%);\u003c/p\u003e\u003cp\u003e2: \u003cb\u003e11\u003c/b\u003e (8.7%);\u003c/p\u003e\u003cp\u003e1: \u003cb\u003e5\u003c/b\u003e (4%);\u003c/p\u003e\u003cp\u003e0: \u003cb\u003e10\u003c/b\u003e (7.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMRC score - summary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean 3.69; median 4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComorbidities / risk factors, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType 2 diabetes mellitus \u003cb\u003e53\u003c/b\u003e (42.1%);\u003c/p\u003e\u003cp\u003elong-term corticosteroid therapy \u003cb\u003e41\u003c/b\u003e (32.5%); tobacco use \u003cb\u003e24\u003c/b\u003e (19%);\u003c/p\u003e\u003cp\u003echronic alcohol misuse \u003cb\u003e10\u003c/b\u003e (7.9%);\u003c/p\u003e\u003cp\u003eintravenous drug use \u003cb\u003e3\u003c/b\u003e (2.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of hospital stay, mean (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e35.3 (median 27)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003e1\u003c/sup\u003eBMI = body-mass index; \u003csup\u003e2\u003c/sup\u003eMRC = Medical Research Council muscle strength score\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe cohort consisted predominantly of older patients (mean age 65 years) with a substantial comorbidity burden (type 2 diabetes 42.1%, long-term corticosteroid therapy 32.5%). Clinically, back/neck pain predominated; fever was present in only 17.5%, underscoring the nonspecific presentation. The MRC distribution indicates that 52.4% of patients had a motor deficit, reflecting marked functional impairment at admission.\u003c/p\u003e\u003cp\u003eMRI was performed in all patients. Distribution by spinal segment: cervical 12%, thoracic 20.6%, lumbar 46%; multilevel disease 21.4%. A pre-existing extra-spinal infectious focus was identified in 68 patients, while isolated spinal involvement without another primary focus was present in 58 patients.\u003c/p\u003e\u003cp\u003eAdmission blood cultures were obtained in 103/126 patients; 89/103 (86.4%) were positive, corresponding to 89/126 (70.6%) of the entire cohort. Material from the spinal focus was obtained in all patients (intraoperatively in those undergoing surgery, CT-guided biopsy in non-operative/deferred cases). Tissue cultures were positive in 114/126, negative in 11/126, and contaminated/indeterminate in 1/126; PCR was performed in 10 culture-negative samples. The total number of patients with any microbiological confirmation (blood and/or tissue culture and/or PCR) was 121/126 (96.0%). The most frequently identified pathogen was \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (85/121, 70.3%), followed by \u003cem\u003eEnterobacterales\u003c/em\u003e (18/121, 14.9%; most commonly \u003cem\u003eEscherichia coli, Klebsiella pneumoniae, Salmonella Enteritidis\u003c/em\u003e) and streptococci (16/121, 13.2%).\u003c/p\u003e\u003cp\u003ePrimary conservative therapy (antibiotics plus orthosis) was selected for 18/126 patients; it was successful in 14/18. Owing to failure of conservative management, 4 of these patients subsequently underwent surgery; an additional 17 patients were referred for surgery after failure of conservative treatment at referring hospitals (total 21 operated after failed conservative care).\u003c/p\u003e\u003cp\u003ePrimary early surgery was indicated in 74/126 patients: a delayed procedure after antibiotics in 17/126. Surgical management is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurgical management of spondylodiscitis (N\u0026thinsp;=\u0026thinsp;108). Values are n (% of operated patients). Timing categories are mutually exclusive and refer to the index operation.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eTiming of surgery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary (early) procedure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e58.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDelayed procedure after antibiotics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAfter failure of conservative therapy*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eNumber of stages\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle-stage procedure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e78.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMultistage procedure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eType of surgical procedure\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDebridement\u0026thinsp;+\u0026thinsp;decompression without instrumentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e70.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInstrumented decompression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInstrumentation alone (no decompression)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCombined multistage procedures\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eSurgical approach\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePosterior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e83.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnterior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCombined (anterior\u0026thinsp;+\u0026thinsp;posterior / lateral\u0026thinsp;+\u0026thinsp;posterior)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLateral alone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: 4 patients failed conservative therapy at our center and were subsequently operated; \u003cb\u003e13\u003c/b\u003e patients were referred for surgery after failure of conservative treatment at referring institutions (total 17).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEarly surgical intervention and a single-stage strategy predominated. Debridement with decompression without instrumentation was the most common procedure; instrumented procedures represented a minority. The posterior approach was dominant; a pure lateral approach was not used. The high prevalence of epidural abscesses at presentation reflects the severity of cases treated at a tertiary center and explains the predominance of decompressive procedures.\u003c/p\u003e\u003cp\u003eTargeted antibiotic therapy was guided by culture results; when the pathogen was unknown, empiric therapy was used in severe septic presentations according to local microbiology. The duration of antibiotic treatment could not be reliably retrieved in many cases and is therefore not reported.\u003c/p\u003e\u003cp\u003eTreatment course and outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTreatment outcomes in our spondylodiscitis cohort \u003cem\u003eCohort N\u0026thinsp;=\u0026thinsp;126; survivors at discharge n\u0026thinsp;=\u0026thinsp;119.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn-hospital course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMultiorgan failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIn-hospital mortality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDischarge disposition (of all 126)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFurther inpatient/rehabilitation care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDied in hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026mdash; of which (subset of \u0026ldquo;Further care\u0026rdquo;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDirect transfer to a rehabilitation institute\u0026sup1;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelapse (of all 126)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDisease relapse after treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e**Pain at discharge (of survivors, n\u0026thinsp;=\u0026thinsp;119)**\u0026sup2;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eImproved\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e90\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e71.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnchanged\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWorsened\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImplant-related complications\u0026sup3;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplications related to spinal instrumentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\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\u0026sup1; Subset of the \u0026ldquo;Further inpatient/rehabilitation care\u0026rdquo; group.\u003c/p\u003e\u003cp\u003e\u0026sup2; Pain assessed among survivors only (n\u0026thinsp;=\u0026thinsp;119). Percentages are calculated out of 119.\u003c/p\u003e\u003cp\u003e\u0026sup3;Assessed among instrumented cases (denominator detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); no implant-related complications were observed.\u003c/p\u003e\u003cp\u003eDuring hospitalization, multiorgan failure occurred in 35% and in-hospital mortality was 5.6%. Most patients were discharged to subsequent inpatient/rehabilitation care (73.8%), with 7.9% transferred directly to a rehabilitation institute. Relapse was documented in nearly one quarter of the cohort. Pain relief at discharge was achieved in the vast majority (80.9% with no pain or improved pain), and we observed no complications related to spinal instrumentation.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this single-center retrospective cohort of 126 patients with spondylodiscitis, surgical treatment was indicated in 108/126 (85.7%), reflecting the neurosurgical setting\u0026mdash;patients not primarily requiring surgery are typically admitted to internal medicine wards. A definitive single-stage approach predominated (85/108, 78.7%). The most frequent procedure was surgical debridement with decompression without instrumentation (76/108, 70.4%). Instrumented procedures accounted for 32/108 (29.6%), of which stand-alone stabilization without canal decompression represented 4/108 (3.7%). We recorded no instrumentation-related mechanical failures. An epidural abscess was present in 98/108 (90.7%) of operated cases, confirmed intraoperatively or on preoperative MRI, explaining both the predominance of decompressive procedures and the dominant posterior approach (90/108, 83.3%). Microbiological verification was high: tissue cultures from the focus were positive in 114/126 (90.5%); blood cultures were positive in 89/103 (86.4%) of those obtained (89/126, 70.6% of the entire cohort). The most common pathogen was Staphylococcus aureus (85/121, 70.3% of cases with confirmed etiology). Clinical outcomes mirror the severity of the cohort (multiorgan failure 44/126, 35.0%; in-hospital mortality 7/126, 5.6%); nevertheless, most patients were discharged with reduced or no pain (96/119 survivors, 80.9%), and relapse occurred in 29/126 (23.0%). Primary conservative management was chosen in 18/126 (14.3%) and was successful in 14/18; failure of conservative therapy necessitated surgery in 21 patients (including referrals). Published reviews and observational studies indicate that conservative treatment is effective in a subset of patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], yet surgical indications remain heterogeneous and often lack clear algorithms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our data add nuance: with early surgical indication in the presence of an epidural abscess, threatened or manifest instability, progressive neurological deficit, or antibiotic failure, debridement and decompression without instrumentation often suffice; instrumentation appears safe when instability is demonstrated, including in florid infection\u0026mdash;provided meticulous debridement and targeted antimicrobial therapy are employed. The high diagnostic yield of tissue sampling and blood cultures underscores the value of early, high-quality sampling before or immediately after initiation of therapy. Antibiotic duration is not reported here due to incomplete ascertainment; recommended courses are typically 6\u0026ndash;8 weeks [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A definitive consensus on optimal duration and the frequency of follow-up MRI is lacking [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe high prevalence of epidural abscesses and functional burden at admission (mRC skewed toward lower scores) reflects selection of more severe cases referred to our center. The predominance of posterior approaches aligns with the need for urgent decompression; combined and anterior procedures were reserved for anatomically or biomechanically demanding situations. The absence of implant-related complications in our cohort supports the use of instrumentation when instability criteria are met, while not implying that instrumentation is universally required.\u003c/p\u003e\u003cp\u003eLimitations include: (i) retrospective design without a control group and without inferential analyses, limiting causal inference and exposing the data to selection and information bias; (ii) single-center setting, which may limit generalizability; (iii) incomplete capture of the entire conservatively treated population across specialties, as spondylodiscitis is multidisciplinary and many patients are treated outside neurosurgery; (iv) imperfect post-discharge follow-up across multiple post-acute facilities, limiting precise ascertainment of antibiotic start/stop dates (intravenous and oral) and late complications/relapses; (v) absence of standardized cross-disciplinary protocols for follow-up imaging, potentially introducing heterogeneity in indications for re-intervention; and (vi) antibiotic duration (IV and oral) was not analyzed due to incomplete documentation and inter-facility variation in prescribing, precluding adjustment for antimicrobial exposure in outcome comparisons.\u003c/p\u003e\u003cp\u003eOur findings support a pragmatic algorithm: early microbiological sampling; early decompression and debridement in epidural abscess or neurological deficit; and instrumentation when instability is confirmed, without an observed increase in implant-related complications in our series. Prospective multicenter studies should aim to: (i) standardize surgical indication criteria; (ii) optimize IV/PO antibiotic duration and the role of early switch to oral therapy; (iii) define follow-up MRI protocols, particularly in the post-operative and post-antibiotic periods; and (iv) validate predictors of relapse.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eConservative therapy remains the standard for uncomplicated spondylodiscitis, with targeted\u0026mdash;often prolonged\u0026mdash;antimicrobial treatment as a cornerstone. Staphylococcus aureus predominates microbiologically; early blood cultures and sampling from the spinal focus are therefore essential, with repeat sampling advisable when negative or etiology remains unclear. Surgical indications include, in particular, diagnostic tissue sampling, neurological deficit or its progression, failure of conservative therapy, epidural abscess, and instability or extensive disease. In our cohort, early surgical source control with decompression without instrumentation sufficed in most cases; instrumentation was effective and safe when instability was demonstrated, and we observed no implant-related complications. Meticulous debridement and subsequent targeted antimicrobial therapy are key to success. CT-guided sampling proved a useful adjunct to establish etiology and guide therapy in unclear or non-operative cases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eEthics approval and consent to participate: The Ethical Committee\u003c/b\u003e of the University Hospital Hradec Kralove, Hradec Kralove, Czech Republic (Chairperson Jiri Vortel, MD) determined that this retrospective chart review was exempt from full review and that written informed consent was not required due to the use of de-identified data. The study adhered to the Declaration of Helsinki and applicable data-protection regulations. All data were de-identified prior to analysis; no direct patient identifiers were collected (GDPR-compliant).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication.\u003c/strong\u003e\u003cp\u003eNot applicable (no individual person\u0026rsquo;s data are included).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests.\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e\u003cp\u003eThe authors certify that there are no conflicts of interest with any financial organization regarding the materials discussed in this manuscript.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis research was supported by MH CZ \u0026ndash; DRO (UHHK, 00179906), this research received no external funding. There was no financial interest in the outcomes from the institution; this is institutional support for research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization, P.T. and L.R.; methodology, P.T., L.R. software, M.C..; validation, L.R.; formal analysis, L.R., T.H., T.Č.; investigation, P.T., R.K., T.H., P.R. L.R., J.T.; re-sources, P.T.; data curation \u0026ndash; M.C..; writing\u0026mdash;original draft preparation, P.T.; writing\u0026mdash;review and editing, M.C., T.Č., L.R.; supervision, T.Č., T.H., L.R.; project administration, P.T., M.C.; funding acquisition, P.T. All authors have read and agreed to the published version of the manuscript. All authors participated in critical revision of the manuscript, contributed comments, and approved the final version.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe study protocol and de-identified dataset supporting the findings are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee KY (2014) Comparison of pyogenic spondylitis and tuberculous spondylitis. Asian Spine J 8(2):216\u0026ndash;223\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLang S, Walter N, Heidemanns S (2024) [18F]FDG PET/CT Imaging Is Associated with Lower In-Hospital Mortality in Patients with Pyogenic Spondylodiscitis\u0026mdash;A Registry-Based Analysis of 29,362 Cases. Antibiotics\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaryeh K, Anazor F, Iyer S, Rajagopal TS (2022) Spondylodiscitis in adults: diagnosis and management. Br J Hosp Med\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrammatico L, Baron S, Rusch E, Lepage B, Surer N, Desenclos JC et al (2008) Epidemiology of vertebral osteomyelitis in France: analysis of hospital-discharge data 2002\u0026ndash;2003. Epidemiol Infect 136:653\u0026ndash;660\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStangenberg M, Mende KC, Mohme M (2021) Influence of microbiological diagnosis on the clinical course of spondylodiscitis. Infection\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLima D, Lopes N, Rodrigues D (2024) Diagnosis and Treatment of Spondylodiscitis: Insights From a Five-Year Single-Center Study. Cureus\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePojskic M, Carl B, Schm\u0026ouml;ckel V (2021) Neurosurgical management and outcome parameters in 237 patients with spondylodiscitis. Brain Sci\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePiccolo CL, Villanacci A, Di Stefano F (2024) Spondylodiscitis and Its Mimickers: A Pictorial Review. Biomedicines\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSinger M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M et al (2016) The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 315(8):801\u0026ndash;810\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQuinones-Hinojosa JP, Jacobs R, Rosenberg WS, Weinstein PR (2004) General principles in the medical and surgical management of spinal infections: a multidisciplinary approach. Neurosurg Focus 17(6):E1\u0026ndash;E\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThavarajasingam S, Vemulapalli K, Vishnu KS (2023) Conservative versus early surgical treatment in the management of pyogenic spondylodiscitis: a systematic review and meta-analysis. Sci Rep\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeuhoff J, Kr\u0026auml;mer A, Thavarajasingam SG (2024) Comparing Conservative and Early Surgical Treatments for Pyogenic Spondylodiskitis: An International Propensity Score\u0026ndash;Matched Retrospective Outcome Analysis. Neurosurgery\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBigdon SF, Vialle E, Dandurand C (2025) Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Evaluation and Treatment of Pyogenic Spondylodiscitis of the Spine: AO Spine Knowledge Forum Trauma and Infection. Global Spine J\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMotov S, Stemmer B, Krau\u0026szlig; P (2024) Clinical and surgical outcome in patients with cervical spondylodiscitis\u0026mdash;a single-center retrospective case series of 24 patients. Front Surg\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK et al (2015) 2015 infectious diseases society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adultsa. Clin Infect Dis 61(6):e26\u0026ndash;e46\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJeong SJ, Choi SW, Youm JY, Kim HW, Ha HG, Yi JS (2014) Microbiology and epidemiology of infectious spinal disease. J Korean Neurosurg Soc 56:21\u0026ndash;27\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuerado E, Cerv\u0026aacute;n AM (2012) Surgical treatment of spondylodiscitis: an update. Int Orthop 36:413\u0026ndash;420\u003c/span\u003e\u003c/li\u003e\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":"spondylodiscitis, spondylitis, epidural abscess, magnetic resonance imaging, antibiotic therapy, instrumentation, spine, intervertebral disc","lastPublishedDoi":"10.21203/rs.3.rs-8005034/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8005034/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction/background:\u003c/h2\u003e\u003cp\u003ePyogenic spondylodiscitis is a serious spinal infection. Surgical debridement with or without stabilization is an established adjunct to antibiotic therapy, yet indication criteria and operative extent vary across the literature. We evaluated outcomes of surgically treated spondylodiscitis at our institution (2015\u0026ndash;2024).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively analyzed consecutive patients indicated for surgery. Variables included procedure type (decompression alone vs. instrumentation), presence of epidural abscess, reoperation for relapse or new-onset instability, microbiology, length of hospital stay (LOS), early outcomes, and admission clinical status.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWe identified 126 patients (87 men, 69%); mean age 65 years (range 13\u0026ndash;91). Surgery was performed in 108 patients: decompression alone in 76 (70.4%), instrumented decompression in 21 (19.4%), standalone instrumentation in 4 (3.7%), and multistage combined procedures in 7 (6.5%). An epidural abscess was present at the index operation in 98/108 (90.7%), confirmed intraoperatively or on preoperative MRI. Disease relapse occurred in 23.1%; reoperation for progressive instability in 15.7%. The most common pathogen was Staphylococcus aureus (55%), followed by streptococci (11%) and Enterobacterales (14%). Mean LOS was 35.3 days (median 27). Multiorgan failure developed in 44 patients (35%). Seven patients died. No implant-related complications were observed.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eIn most operated cases, early surgical source control with decompression without instrumentation was sufficient. When instability is demonstrated, instrumentation is safe even in active infection provided meticulous debridement and targeted antibiotic therapy are employed. The high diagnostic yield of blood cultures and tissue samples supports early acquisition and repetition as needed.\u003c/p\u003e","manuscriptTitle":"Surgical Management of Spondylodiscitis: A Single-Center Retrospective Analysis of 126 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-17 10:55:56","doi":"10.21203/rs.3.rs-8005034/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":"8c16efda-ab65-4899-8dac-aae35032a720","owner":[],"postedDate":"November 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-21T13:53:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-17 10:55:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8005034","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8005034","identity":"rs-8005034","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}