Risk Factors for Surgical Treatment in the Management of Pyogenic Spondylitis

Risk Factors for Surgical Treatment in the Management of Pyogenic Spondylitis | 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 Risk Factors for Surgical Treatment in the Management of Pyogenic Spondylitis Hiromitsu Takaoka, Ko Takano, Osamu Matsushige, Seiji Ohtori This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6540804/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 Purpose The frequency of pyogenic spondylitis has increased owing to an aging population and a growing number of immunocompromised patients. This study investigated risk factors for surgery in patients with pyogenic spondylitis treated at our hospital. Methods Seventy-one patients (52 males, 19 females) with pyogenic spondylitis treated from 2014 to 2023 were included. Conservative treatment was the primary approach, with surgery indicated for cases resistant to conservative management or with worsening neurological symptoms. Initial surgery involved minimally invasive stabilization, with debridement and anterior fixation performed when necessary. Age, sex, body mass index (BMI), fever rate, hospitalization duration, time to diagnosis, bacterial presence, blood tests, epidural abscess, immunocompromised status, and comorbidities were compared between the conservative and surgical treatment groups. Multivariate analysis identified risk factors for surgery. Results No significant differences were found in age, sex, BMI, fever rate, hospitalization duration, culture-positive rate, or blood tests. However, the prevalence of epidural abscess (36.6% vs. 60%) and diabetes mellitus (22% vs. 53.3%) was significantly higher in the surgical group (P < 0.05). Epidural abscess (odds ratio: 3.79, P = 0.0198) and diabetes mellitus (odds ratio: 3.83, P = 0.0261) were independent risk factors in the logistic regression analysis. Conclusion This study found no significant differences in inflammatory markers at admission or during hospitalization. Patients with epidural abscesses and diabetes mellitus were more likely to require surgery. Advances in minimally invasive surgery may have changed the risk factors for surgery compared with previous years. Pyogenic spondylitis epidural abscess diabetes mellitus minimally invasive surgery risk factors surgical treatment Introduction Pyogenic spondylitis can cause significant neurological damage and life-threatening complications if not treated appropriately. Although relatively rare, its incidence has increased in recent years, likely because of an aging population and a growing number of immunocompromised patients [ 1 ]. Pyogenic spondylitis typically presents with severe pain at the site of infection and fever, although fever is often absent [ 2 ]. The primary treatment is conservative management with antimicrobial agents; however, surgery becomes necessary when conservative therapy fails or when neurological deficits and spinal instability progress [ 3 – 7 ]. Clinical decision-making is complicated by the lack of clearly defined risk factors that indicate when a shift from conservative to surgical treatment is warranted. This study aimed to compare patients treated conservatively and those who underwent surgery for pyogenic spondylitis and to identify risk factors associated with the need for surgical intervention. Methods Treatment protocol This study was a retrospective study and did not require informed consent because data were collected from existing patient records and “de-identification criteria” were followed to protect the confidentiality of personal information. The inclusion criteria consisted of patients diagnosed with pyogenic spondylitis who were hospitalized for treatment. The exclusion criteria included infections following spinal surgery and patients treated at other hospitals for whom detailed clinical information was unavailable. Patients presenting with fever and back pain and clinically suspected of having pyogenic spondylitis initially underwent plain spinal radiography. This was followed by magnetic resonance imaging, along with laboratory tests including C-reactive protein (CRP) levels and white blood cell (WBC) counts, to establish a definitive diagnosis. Blood cultures and biopsies were performed to identify causative bacterial pathogens. Conservative treatment began with intravenous antimicrobial therapy, tailored according to the results of microbiological cultures and antibiotic susceptibility testing. Patients remained on bed rest for approximately two weeks before being fitted with a thoracolumbosacral orthosis. Antimicrobial therapy was continued for 12–24 weeks. Surgical treatment was indicated for patients who showed poor response to conservative therapy—such as persistent elevation of CRP, ongoing fever, or sustained back pain—accompanied by progressive neurological deficits or worsening spinal instability and kyphosis. The surgical approach involved a two-stage procedure: initial minimally invasive spine stabilization using percutaneous pedicle screws, followed by debridement of the infected tissue and anterior fixation if infection control was not achieved with the initial procedure. The thoracolumbosacral orthosis was worn for 3–6 months postoperatively. Ethical approval for this study was obtained from our hospital (approval number: 0315). The study period spanned from January 2014 to December 2023. Patients were divided into two groups: the conservative treatment group (group C) and the surgical treatment group (group O). The following variables were compared between the two groups using univariate analysis: age, sex, body mass index, presence of fever, length of hospitalization, duration from symptom onset to diagnosis, bacterial identification, immunocompromised status, use of antipyretic drugs, presence of an epidural abscess, comorbidities, and laboratory data (CRP, WBC, creatinine, estimated glomerular filtration rate on admission, and CRP and WBC levels one week after hospitalization). Multivariate analysis was also performed to identify risk factors associated with the need for surgical treatment. Fever was defined as a body temperature exceeding 37.5°C at the initial visit. Patients were classified as immunocompromised if they had diabetes mellitus, chronic renal failure, liver cirrhosis, or a malignant disease. Statistical analysis Categorical variables are presented as frequencies and percentages, and continuous variables are presented as means ± standard deviations. The chi-square test was used to analyze categorical variables, whereas the Mann–Whitney U test was applied to continuous variables. Multivariate logistic regression analysis was performed to evaluate the independent association between variables that showed significant differences and the likelihood of undergoing surgical treatment. Adjusted odds ratios and 95% confidence intervals were calculated. All statistical tests were two-tailed, and a P-value < 0.05 was considered statistically significant. All analyses were conducted using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). Specifically, EZR is a modified version of R Commander, designed to include statistical functions commonly used in biostatistics [ 8 ]. Results The study included 71 patients (52 males, 19 females). Group C consisted of 41 patients (28 males, 13 females) with a mean age of 71.8 ± 12.7 years, whereas group O included 30 patients (24 males, 6 females) with a mean age of 71.8 ± 13.2 years. The mean body mass index was 23.9 ± 5.6 kg/m 2 in group C and 23.6 ± 5.3 kg/m 2 in group O (Table 1). Debridement and anterior fixation were required in three surgical cases. No significant differences were observed between the two groups in terms of fever rate, length of hospitalization, time to diagnosis, culture-positive rate, and use of antipyretic drugs during hospitalization. However, the prevalence of epidural abscess was significantly higher in group O (36.6% vs. 60%, P = 0.0487; Table 2). Regarding coexisting diseases, the prevalence of diabetes mellitus was significantly higher in group O (22% vs. 53.3%, P = 0.011). In contrast, no significant differences were observed between the groups in the prevalence of chronic renal failure, acute coronary syndrome, malignancy, liver cirrhosis, cerebral infarction, valvular heart disease, or arrhythmia (Table 3). In terms of laboratory test results, no significant differences were found in CRP levels on admission, WBC counts on admission, CRP levels after admission, WBC counts after admission, creatinine levels on admission, or estimated glomerular filtration rate on admission (Table 4). Multivariate logistic regression analysis was performed for the variables showing significant differences: epidural abscess, diabetes mellitus, and immunocompromised status. The analysis revealed that epidural abscess (odds ratio: 3.79, P = 0.0198) and diabetes mellitus (odds ratio: 3.83, P = 0.0261) were independent risk factors for surgical treatment (Table 5). Discussion The rate of patients requiring surgery for pyogenic spondylitis despite conservative treatment has been reported in several studies, with figures ranging from 27–55% [ 3 , 9 – 12 ]. In this study, the surgical rate was 42%, which aligns with the rates reported by other authors. Previously, direct debridement and fixation of the infected area were typically performed in a single operation [ 13 , 14 ]. However, recent advances in surgical treatment strategies for pyogenic spondylitis have led to the widespread adoption of minimally invasive spine stabilization using percutaneous pedicle screws as the initial surgical approach [ 15 ]. This technique has proven to be an effective minimally invasive option for elderly and immunocompromised patients, providing spinal stability while avoiding direct treatment of the infected site. Spinal stabilization alone has been shown to improve surgical outcomes by temporarily controlling inflammation and enhancing the effectiveness of antimicrobial therapy. In this study, as in previous reports, a certain percentage of patients required surgery. However, the shift in treatment strategy may have influenced the criteria for surgical indications and outcomes. The use of minimally invasive fixation techniques may have impacted the overall surgery rate by enabling surgery for patients who would have previously been considered ineligible owing to high surgical risk. In this study, epidural abscess and diabetes mellitus were identified as independent risk factors for requiring surgical treatment in pyogenic spondylitis. Epidural abscess is a condition with a high potential to cause spinal cord compression and neurological deficits. It has been previously reported as a risk factor leading to surgery [ 16 ]. Similarly, the present study found that the presence of an epidural abscess was strongly associated with the need for surgical intervention. This highlights the importance of performing an early magnetic resonance imaging scan to assess for an epidural abscess when a spinal infection is suspected. The study also demonstrated that patients with diabetes are at higher risk of requiring surgery. Diabetes is a known risk factor for impaired immune function and increased infection severity. Furthermore, diabetes is generally considered a risk factor for perioperative infections [ 17 , 18 ]. However, glycemic control may reduce the risk of perioperative complications [ 19 ]. Langlois et al. reported that higher postoperative blood glucose levels were associated with longer operative times, increased blood loss, and a greater need for blood transfusions [ 20 ]. In the present study, no perioperative complications, including postoperative infection, were observed in patients with diabetes mellitus. This may be attributed to recent advancements in minimally invasive surgery [ 21 ], which have reduced operative times, minimized blood loss, and decreased the need for blood transfusion. In addition, Milosevic et al. reported that diabetes mellitus is associated with increased severity of pyogenic spondylitis [ 22 ], which may explain why diabetes is a risk factor for requiring surgical treatment. On the other hand, this study found no significant differences in inflammatory markers, such as CRP level and WBC count, between the surgical and conservative treatment groups at the time of admission. Previous studies, such as those by Kugimiya et al. and Fukuda et al., have reported that high CRP levels are a risk factor for surgery [ 9 , 16 ]. The results of this study suggest that these inflammatory markers have limited utility as independent indicators for determining the need for surgical treatment. Recent advances in antimicrobial therapy may have made infection control easier, thus reducing the impact of these markers. The limitations of this study include its retrospective, single-center design and the lack of clear criteria for surgical indications. In conclusion, epidural abscess and diabetes mellitus were identified as risk factors for requiring surgical treatment in pyogenic spondylitis. The results of this study suggest that these factors may serve as useful guidelines for diagnostic and therapeutic decision-making in clinical practice. Advances in minimally invasive surgery have made surgical treatment a more viable option than in the past, and this progress may have altered the risk factors associated with surgery. Declarations Author Contribution HT designed the study, collected and analyzed the data, wrote manuscript. KT collected and analyzed the data, supervised the study. And all authors have read, reviewed, and approved the article. Acknowledgement We would like to thank Editage (www.editage.com) for English language editing. References Nagashima H, Nanjo Y, Tanida A, Dokai T, Teshima R (2012) Clinical features of spinal infection in individuals older than eighty years. Int Orthop. 36:1229-1234. Sapico FL, Montgomerie JZ (1979) Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis. 1:754-776. Valancius K, Hansen ES, Høy K, Helmig P, Niedermann B, Bünger C (2013) Failure modes in conservative and surgical management of infectious spondylodiscitis. Eur Spine J. 22:1837-1844. Guerado E, Cerván AM (2012) Surgical treatment of spondylodiscitis. An update. Int Orthop. 36:413-420. Cheung WY, Luk KD (2012) Pyogenic spondylitis. Int Orthop. 36:397-404. Skaf GS, Domloj NT, Fehlings MG, Bouclaous CH, Sabbagh AS, Kanafani ZA, Kanj SS (2010) Pyogenic spondylodiscitis: an overview. J Infect Public Health.3:5-16. Zarghooni K, Röllinghoff M, Sobottke R, Eysel P (2012) Treatment of spondylodiscitis. Int Orthop. 36:405-411. Kanda Y (2013) Investigation of the freely available easy-to-use software 'EZR' for medical statistics. Bone Marrow Transplant. 48:452-458. Fukuda K, Miyamoto H, Uno K, Okada Y (2014) Indications and limitations of conservative treatment for pyogenic spondylitis. J Spinal Disord Tech. 27:316-320. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ (2000) Hematogenous pyogenic spinal infections and their surgical management. Spine（Phila Pa 1976）. 25：1668-1679 Cebrián Parra JL, Saez-Arenillas Martin A, Urda Martínez-Aedo AL , Soler Ivañez I, Agreda E, Lopez-Duran Stern L (2012) Manegement of infectious discitis. Outcome in one hundred and eight patients in a university hospital. Int Orthop. 36：239-244 Butler JS, Shelly MJ, Timlin M, Powderly WG, O'Byrne JM (2006) Nontuberculous pyogenic spinal infection in adults: a 12-year experience from a tertiary referral center. Spine (Phila Pa 1976). 31:2695-2700. Emery SE, Chan DP, Woodward HR (1989) Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine (Phila Pa 1976). 14:284-291. Fang D, Cheung KM, Dos Remedios ID, Lee YK, Leong JC (1994) Pyogenic vertebral osteomyelitis: treatment by anterior spinal debridement and fusion. J Spinal Disord. 7:173-180. Ishihara S, Funao H, Isogai N, Ishihara M, Saito T, Ishii K (2022) Minimally Invasive Spine Stabilization for Pyogenic Spondylodiscitis: A 23-Case Series and Review of Literature. Medicina (Kaunas). 58:754. Kugimiya F, Muraki S, Nagakura D, Umekoji H, Oda H, Takahashi K (2017) Predictors of conservative treatment for pyogenic spondylitis. Spine Surg Relat Res. 1:135-139. Luo M, Cao Q, Wang D, Tan R, Shi Y, Chen J, Chen R, Tang G, Chen L, Mei Z, Xiao Z (2022) The impact of diabetes on postoperative outcomes following spine surgery: A meta-analysis of 40 cohort studies with 2.9 million participants. Int J Surg. 104:106789. Guzman JZ, Skovrlj B, Shin J, Hecht AC, Qureshi SA, Iatridis JC, Cho SK (2014) The impact of diabetes mellitus on patients undergoing degenerative cervical spine surgery. Spine (Phila Pa 1976). 39:1656-1665 Peng W, Liang Y, Lu T, Li M, Li DS, Du KH, Wu JH (2019) Multivariate analysis of incision infection after posterior lumbar surgery in diabetic patients: a single-center retrospective analysis. Medicine (Baltimore). 98 :e15935. Langlois J, Bouyer B, Larroque B, Dauzac C, Guigui P (2014) Glycemic instability of non-diabetic patients after spine surgery: a prospective cohort study. Eur Spine J. 23:2455–2461. Chen WH, Jiang LS, Dai LY (2007) Surgical treatment of pyogenic vertebral osteomyelitis with spinal instrumentation. Eur Spine J. 16:1307-1316. Milosevic B, Cevik M, Urosevic A, Nikolic N, Poluga J, Jovanovic M, Milosevic I, Micic J, Paglietti B, Barac A (2020) Risk factors associated with poor clinical outcome in pyogenic spinal infections: 5-years' intensive care experience. J Infect Dev Ctries. 14:36-41. Tables Tables 1. Patients’ demographic data group C group O p value Number of cases 41 30 Age (y.o.) 71.8±12.7 71.8±13.2 0.694 Sex Male 28 Female 13 Male 24 Female 6 0.295 BMI(kg/m2) 23.9±5.6 23.6±5.3 0.887 Immunocompromised patient(%) 70.7 93.3 0.032 Infectious area Cervical 1 3 Thoracical 5 5 Lumbar 35 22 Tables 2. Characteristics during hospitalization group C group O p value Fever rate (%) 46.3 56.7 0.474 The length of hospital stay (days) 61.7±50.5 71.8±47.4 0.107 Diagnosis rate of positive (%) 75.5 69.0 0.597 The days of needing to diagnosis (days) 17.2±22.9 26.3±30.2 0.411 Rate of the used fever medicine before diagnosis (%) 12.5 17.2 0.732 Epidural.abscess (%) 36.6 60 0.0487 Tables 3. Coexisting disease (%) group C group O p value Diabetesmellitus 22 53.3 0.011 Chronic renal failure 24.4 23.3 1 Acute coronary syndrome 14.6 16.7 1 Malignancy 19.5 10 0.34 Liver cirrhosis 2.4 6.7 0.57 Cerebral infarction 14.6 10 0.72 Valvular heart disease 19.5 10 0.34 Arrhythmia 12.2 10 1 Tables 4. Laboratory test results group C group O p value CRP on admission (mg/L) 12.9±0.7 12.6±9.4 0.875 WBC on admission ( μ L) 9700±3800 10600±4600 0.56 CRP after admission (mg/L) 6.5±6.5 7.0±5.9 0.549 WBC after admission ( μ L) 8150±3096 8055±3320 0.91 Cre on admission (mg/L) 1.7±2.1 1.5±1.6 0.442 eGFR on admission (mL/min/1.73 m 2 ) 55.1±26.8 59.9±29.0 0.256 CRP indicates C-reactive protein; WBC, white blood cell; Cre, creatinine; eGFR, estimated Glomerular Filtration Rate Tables 5. Multivariate logistic regression analysis. Odds ratio (95% confidence interval) P value Diabetes mellitus 3.83(1.17-12.5) .026 Epidural abscess 3.79(1.24-11.6) .019 Compromised host 3.97(0.715-22) .115 Additional Declarations No competing interests reported. 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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-6540804","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466683600,"identity":"372e03ee-caf8-49e0-9eef-fd0fcfae5242","order_by":0,"name":"Hiromitsu Takaoka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYBACA2YGNmYGAwsZPiCDgaECKAKVYSagRYKHDaTlwBlitDCAtDAAtQAZDAfbEFpwAnN29muPCwqAWkCMj/MOy5uzNx9g+FHBwG6OQ4tlM0+58Qyww3jKDQ5uO2y4s+dYAmPPGQZmywYcDjvMkybNA9GSJgHUwrjhRo4BM2MbA7PBAaK0zDlsT4QW9mNQLezHJA42HE4kxhY2mC1sEmeOpSdvOHMs4WDPGQncfjl//Jk0zx8bOX7+488kKmqsbTccbz744EeFTTKuEGNg4DFAZjSDmUAnSSTjjiD2B8iMOri4HcE4HQWjYBSMgpECALbUUD2aMNLCAAAAAElFTkSuQmCC","orcid":"","institution":"New Tokyo Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hiromitsu","middleName":"","lastName":"Takaoka","suffix":""},{"id":466683601,"identity":"2cd5a538-43ce-48c3-a7b2-23fa297dbbf3","order_by":1,"name":"Ko Takano","email":"","orcid":"","institution":"New Tokyo Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ko","middleName":"","lastName":"Takano","suffix":""},{"id":466683602,"identity":"5579b633-6848-439d-9622-886e889f0ff3","order_by":2,"name":"Osamu Matsushige","email":"","orcid":"","institution":"New Tokyo Hospital","correspondingAuthor":false,"prefix":"","firstName":"Osamu","middleName":"","lastName":"Matsushige","suffix":""},{"id":466683603,"identity":"239c029a-0311-4843-a0e3-80c7ca9ba99d","order_by":3,"name":"Seiji Ohtori","email":"","orcid":"","institution":"Chiba University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seiji","middleName":"","lastName":"Ohtori","suffix":""}],"badges":[],"createdAt":"2025-04-27 13:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6540804/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6540804/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85793262,"identity":"056dd917-c685-4bd7-a613-d86958c1f61b","added_by":"auto","created_at":"2025-07-01 18:16:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":718840,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6540804/v1/079ee7b2-3432-486c-b2fd-18bb7a79d905.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk Factors for Surgical Treatment in the Management of Pyogenic Spondylitis","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePyogenic spondylitis can cause significant neurological damage and life-threatening complications if not treated appropriately. Although relatively rare, its incidence has increased in recent years, likely because of an aging population and a growing number of immunocompromised patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Pyogenic spondylitis typically presents with severe pain at the site of infection and fever, although fever is often absent [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The primary treatment is conservative management with antimicrobial agents; however, surgery becomes necessary when conservative therapy fails or when neurological deficits and spinal instability progress [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Clinical decision-making is complicated by the lack of clearly defined risk factors that indicate when a shift from conservative to surgical treatment is warranted. This study aimed to compare patients treated conservatively and those who underwent surgery for pyogenic spondylitis and to identify risk factors associated with the need for surgical intervention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTreatment protocol\u003c/h2\u003e \u003cp\u003eThis study was a retrospective study and did not require informed consent because data were collected from existing patient records and \u0026ldquo;de-identification criteria\u0026rdquo; were followed to protect the confidentiality of personal information. The inclusion criteria consisted of patients diagnosed with pyogenic spondylitis who were hospitalized for treatment. The exclusion criteria included infections following spinal surgery and patients treated at other hospitals for whom detailed clinical information was unavailable.\u003c/p\u003e \u003cp\u003ePatients presenting with fever and back pain and clinically suspected of having pyogenic spondylitis initially underwent plain spinal radiography. This was followed by magnetic resonance imaging, along with laboratory tests including C-reactive protein (CRP) levels and white blood cell (WBC) counts, to establish a definitive diagnosis. Blood cultures and biopsies were performed to identify causative bacterial pathogens.\u003c/p\u003e \u003cp\u003eConservative treatment began with intravenous antimicrobial therapy, tailored according to the results of microbiological cultures and antibiotic susceptibility testing. Patients remained on bed rest for approximately two weeks before being fitted with a thoracolumbosacral orthosis. Antimicrobial therapy was continued for 12\u0026ndash;24 weeks.\u003c/p\u003e \u003cp\u003eSurgical treatment was indicated for patients who showed poor response to conservative therapy\u0026mdash;such as persistent elevation of CRP, ongoing fever, or sustained back pain\u0026mdash;accompanied by progressive neurological deficits or worsening spinal instability and kyphosis. The surgical approach involved a two-stage procedure: initial minimally invasive spine stabilization using percutaneous pedicle screws, followed by debridement of the infected tissue and anterior fixation if infection control was not achieved with the initial procedure. The thoracolumbosacral orthosis was worn for 3\u0026ndash;6 months postoperatively.\u003c/p\u003e \u003cp\u003eEthical approval for this study was obtained from our hospital (approval number: 0315). The study period spanned from January 2014 to December 2023. Patients were divided into two groups: the conservative treatment group (group C) and the surgical treatment group (group O). The following variables were compared between the two groups using univariate analysis: age, sex, body mass index, presence of fever, length of hospitalization, duration from symptom onset to diagnosis, bacterial identification, immunocompromised status, use of antipyretic drugs, presence of an epidural abscess, comorbidities, and laboratory data (CRP, WBC, creatinine, estimated glomerular filtration rate on admission, and CRP and WBC levels one week after hospitalization). Multivariate analysis was also performed to identify risk factors associated with the need for surgical treatment. Fever was defined as a body temperature exceeding 37.5\u0026deg;C at the initial visit. Patients were classified as immunocompromised if they had diabetes mellitus, chronic renal failure, liver cirrhosis, or a malignant disease.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eCategorical variables are presented as frequencies and percentages, and continuous variables are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations. The chi-square test was used to analyze categorical variables, whereas the Mann\u0026ndash;Whitney U test was applied to continuous variables. Multivariate logistic regression analysis was performed to evaluate the independent association between variables that showed significant differences and the likelihood of undergoing surgical treatment. Adjusted odds ratios and 95% confidence intervals were calculated. All statistical tests were two-tailed, and a P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All analyses were conducted using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). Specifically, EZR is a modified version of R Commander, designed to include statistical functions commonly used in biostatistics [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 71 patients (52 males, 19 females). Group C consisted of 41 patients (28 males, 13 females) with a mean age of 71.8 \u0026plusmn; 12.7 years, whereas group O included 30 patients (24 males, 6 females) with a mean age of 71.8\u0026nbsp;\u0026plusmn;\u0026nbsp;13.2 years. The mean body mass index was 23.9 \u0026plusmn; 5.6 kg/m\u003csup\u003e2\u003c/sup\u003e in group C and 23.6 \u0026plusmn; 5.3 kg/m\u003csup\u003e2\u003c/sup\u003e in group O (Table 1). Debridement and anterior fixation were required in three surgical cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo significant differences were observed between the two groups in terms of fever rate, length of hospitalization, time to diagnosis, culture-positive rate, and use of antipyretic drugs during hospitalization. However, the prevalence of epidural abscess was significantly higher in group O (36.6% vs. 60%, P = 0.0487; Table 2). Regarding coexisting diseases, the prevalence of diabetes mellitus was significantly higher in group O (22% vs. 53.3%, P = 0.011). In contrast, no significant differences were observed between the groups in the prevalence of chronic renal failure, acute coronary syndrome, malignancy, liver cirrhosis, cerebral infarction, valvular heart disease, or arrhythmia (Table 3). In terms of laboratory test results, no significant differences were found in CRP levels on admission, WBC counts on admission, CRP levels after admission, WBC counts after admission, creatinine levels on admission, or estimated glomerular filtration rate on admission (Table 4). Multivariate logistic regression analysis was performed for the variables showing significant differences: epidural abscess, diabetes mellitus, and immunocompromised status. The analysis revealed that epidural abscess (odds ratio: 3.79, P = 0.0198) and diabetes mellitus (odds ratio: 3.83, P = 0.0261) were independent risk factors for surgical treatment (Table 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe rate of patients requiring surgery for pyogenic spondylitis despite conservative treatment has been reported in several studies, with figures ranging from 27\u0026ndash;55% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this study, the surgical rate was 42%, which aligns with the rates reported by other authors.\u003c/p\u003e \u003cp\u003ePreviously, direct debridement and fixation of the infected area were typically performed in a single operation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, recent advances in surgical treatment strategies for pyogenic spondylitis have led to the widespread adoption of minimally invasive spine stabilization using percutaneous pedicle screws as the initial surgical approach [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This technique has proven to be an effective minimally invasive option for elderly and immunocompromised patients, providing spinal stability while avoiding direct treatment of the infected site. Spinal stabilization alone has been shown to improve surgical outcomes by temporarily controlling inflammation and enhancing the effectiveness of antimicrobial therapy. In this study, as in previous reports, a certain percentage of patients required surgery. However, the shift in treatment strategy may have influenced the criteria for surgical indications and outcomes. The use of minimally invasive fixation techniques may have impacted the overall surgery rate by enabling surgery for patients who would have previously been considered ineligible owing to high surgical risk.\u003c/p\u003e \u003cp\u003eIn this study, epidural abscess and diabetes mellitus were identified as independent risk factors for requiring surgical treatment in pyogenic spondylitis. Epidural abscess is a condition with a high potential to cause spinal cord compression and neurological deficits. It has been previously reported as a risk factor leading to surgery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, the present study found that the presence of an epidural abscess was strongly associated with the need for surgical intervention. This highlights the importance of performing an early magnetic resonance imaging scan to assess for an epidural abscess when a spinal infection is suspected.\u003c/p\u003e \u003cp\u003eThe study also demonstrated that patients with diabetes are at higher risk of requiring surgery. Diabetes is a known risk factor for impaired immune function and increased infection severity. Furthermore, diabetes is generally considered a risk factor for perioperative infections [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, glycemic control may reduce the risk of perioperative complications [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Langlois et al. reported that higher postoperative blood glucose levels were associated with longer operative times, increased blood loss, and a greater need for blood transfusions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the present study, no perioperative complications, including postoperative infection, were observed in patients with diabetes mellitus. This may be attributed to recent advancements in minimally invasive surgery [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], which have reduced operative times, minimized blood loss, and decreased the need for blood transfusion. In addition, Milosevic et al. reported that diabetes mellitus is associated with increased severity of pyogenic spondylitis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which may explain why diabetes is a risk factor for requiring surgical treatment.\u003c/p\u003e \u003cp\u003eOn the other hand, this study found no significant differences in inflammatory markers, such as CRP level and WBC count, between the surgical and conservative treatment groups at the time of admission. Previous studies, such as those by Kugimiya et al. and Fukuda et al., have reported that high CRP levels are a risk factor for surgery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The results of this study suggest that these inflammatory markers have limited utility as independent indicators for determining the need for surgical treatment. Recent advances in antimicrobial therapy may have made infection control easier, thus reducing the impact of these markers. The limitations of this study include its retrospective, single-center design and the lack of clear criteria for surgical indications.\u003c/p\u003e \u003cp\u003eIn conclusion, epidural abscess and diabetes mellitus were identified as risk factors for requiring surgical treatment in pyogenic spondylitis. The results of this study suggest that these factors may serve as useful guidelines for diagnostic and therapeutic decision-making in clinical practice. Advances in minimally invasive surgery have made surgical treatment a more viable option than in the past, and this progress may have altered the risk factors associated with surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHT designed the study, collected and analyzed the data, wrote manuscript. KT collected and analyzed the data, supervised the study. And all authors have read, reviewed, and approved the article.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank Editage (www.editage.com) for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNagashima H, Nanjo Y, Tanida A, Dokai T, Teshima R (2012) Clinical features of spinal infection in individuals older than eighty years. Int Orthop. 36:1229-1234.\u003c/li\u003e\n\u003cli\u003eSapico FL, Montgomerie JZ (1979) Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis. 1:754-776.\u003c/li\u003e\n\u003cli\u003eValancius K, Hansen ES, H\u0026oslash;y K, Helmig P, Niedermann B, B\u0026uuml;nger C (2013) Failure modes in conservative and surgical management of infectious spondylodiscitis. Eur Spine J. 22:1837-1844.\u003c/li\u003e\n\u003cli\u003eGuerado E, Cerv\u0026aacute;n AM (2012) Surgical treatment of spondylodiscitis. An update. Int Orthop. 36:413-420.\u003c/li\u003e\n\u003cli\u003eCheung WY, Luk KD (2012) Pyogenic spondylitis. Int Orthop. 36:397-404.\u003c/li\u003e\n\u003cli\u003eSkaf GS, Domloj NT, Fehlings MG, Bouclaous CH, Sabbagh AS, Kanafani ZA, Kanj SS (2010) Pyogenic spondylodiscitis: an overview. J Infect Public Health.3:5-16.\u003c/li\u003e\n\u003cli\u003eZarghooni K, R\u0026ouml;llinghoff M, Sobottke R, Eysel P (2012) Treatment of spondylodiscitis. Int Orthop. 36:405-411.\u003c/li\u003e\n\u003cli\u003eKanda Y (2013) Investigation of the freely available easy-to-use software \u0026apos;EZR\u0026apos; for medical statistics. Bone Marrow Transplant. 48:452-458.\u003c/li\u003e\n\u003cli\u003eFukuda K, Miyamoto H, Uno K, Okada Y (2014) Indications and limitations of conservative treatment for pyogenic spondylitis. J Spinal Disord Tech. 27:316-320.\u003c/li\u003e\n\u003cli\u003eHadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ (2000) Hematogenous pyogenic spinal infections and their surgical management. Spine（Phila Pa 1976）. 25：1668-1679\u003c/li\u003e\n\u003cli\u003eCebri\u0026aacute;n Parra JL, Saez-Arenillas Martin A, Urda Mart\u0026iacute;nez-Aedo AL , Soler Iva\u0026ntilde;ez I, Agreda E, Lopez-Duran Stern L (2012) Manegement of infectious discitis. Outcome in one hundred and eight patients in a university hospital. Int Orthop. 36：239-244\u003c/li\u003e\n\u003cli\u003eButler JS, Shelly MJ, Timlin M, Powderly WG, O\u0026apos;Byrne JM (2006) Nontuberculous pyogenic spinal infection in adults: a 12-year experience from a tertiary referral center. Spine (Phila Pa 1976). 31:2695-2700.\u003c/li\u003e\n\u003cli\u003eEmery SE, Chan DP, Woodward HR (1989) Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine (Phila Pa 1976). 14:284-291.\u003c/li\u003e\n\u003cli\u003eFang D, Cheung KM, Dos Remedios ID, Lee YK, Leong JC (1994) Pyogenic vertebral osteomyelitis: treatment by anterior spinal debridement and fusion. J Spinal Disord. 7:173-180.\u003c/li\u003e\n\u003cli\u003eIshihara S, Funao H, Isogai N, Ishihara M, Saito T, Ishii K (2022) Minimally Invasive Spine Stabilization for Pyogenic Spondylodiscitis: A 23-Case Series and Review of Literature. Medicina (Kaunas). 58:754.\u003c/li\u003e\n\u003cli\u003eKugimiya F, Muraki S, Nagakura D, Umekoji H, Oda H, Takahashi K (2017) Predictors of conservative treatment for pyogenic spondylitis. Spine Surg Relat Res. 1:135-139.\u003c/li\u003e\n\u003cli\u003eLuo M, Cao Q, Wang D, Tan R, Shi Y, Chen J, Chen R, Tang G, Chen L, Mei Z, Xiao Z (2022) The impact of diabetes on postoperative outcomes following spine surgery: A meta-analysis of 40 cohort studies with 2.9 million participants. Int J Surg. 104:106789.\u003c/li\u003e\n\u003cli\u003eGuzman JZ, Skovrlj B, Shin J, Hecht AC, Qureshi SA, Iatridis JC, Cho SK (2014) The impact of diabetes mellitus on patients undergoing degenerative cervical spine surgery. Spine (Phila Pa 1976). 39:1656-1665\u003c/li\u003e\n\u003cli\u003ePeng W, Liang Y, Lu T, Li M, Li DS, Du KH, Wu JH (2019) Multivariate analysis of incision infection after posterior lumbar surgery in diabetic patients: a single-center retrospective analysis. Medicine (Baltimore). 98 :e15935.\u003c/li\u003e\n\u003cli\u003eLanglois J, Bouyer B, Larroque B, Dauzac C, Guigui P (2014) Glycemic instability of non-diabetic patients after spine surgery: a prospective cohort study. Eur Spine J. 23:2455\u0026ndash;2461.\u003c/li\u003e\n\u003cli\u003eChen WH, Jiang LS, Dai LY (2007) Surgical treatment of pyogenic vertebral osteomyelitis with spinal instrumentation. Eur Spine J. 16:1307-1316.\u003c/li\u003e\n\u003cli\u003eMilosevic B, Cevik M, Urosevic A, Nikolic N, Poluga J, Jovanovic M, Milosevic I, Micic J, Paglietti B, Barac A (2020) Risk factors associated with poor clinical outcome in pyogenic spinal infections: 5-years\u0026apos; intensive care experience. J Infect Dev Ctries. 14:36-41.\u003c/li\u003e\n\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTables 1. Patients\u0026rsquo; demographic data\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"565\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003egroup C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003egroup O\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNumber of cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eAge (y.o.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e71.8\u0026plusmn;12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e71.8\u0026plusmn;13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.694\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003eMale 28 Female 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003eMale 24 Female 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.295\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eBMI(kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e23.9\u0026plusmn;5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e23.6\u0026plusmn;5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eImmunocompromised patient(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e70.7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e93.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eInfectious area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eCervical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eThoracical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 170px;\"\u003e\n \u003cp\u003eLumbar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 159px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 150px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTables 2. Characteristics during hospitalization\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"551\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003egroup C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003egroup O\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eFever rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e46.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.474\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eThe length of hospital stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e61.7\u0026plusmn;50.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e71.8\u0026plusmn;47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eDiagnosis rate of positive (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e75.5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e69.0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eThe days of needing to diagnosis (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e17.2\u0026plusmn;22.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e26.3\u0026plusmn;30.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.411\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eRate of the used fever medicine before diagnosis (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.732\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 331px;\"\u003e\n \u003cp\u003eEpidural.abscess (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e36.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59px;\"\u003e\n \u003cp\u003e0.0487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTables 3. Coexisting disease (%)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003egroup C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003egroup O\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eDiabetesmellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e53.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eChronic renal failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eAcute coronary syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMalignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eLiver cirrhosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eCerebral infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eValvular heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003eArrhythmia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTables 4. Laboratory test results\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003egroup C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003egroup O\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRP on admission (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.9\u0026plusmn;0.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.6\u0026plusmn;9.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.875\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWBC on admission (\u003c/strong\u003e\u003cstrong\u003e\u0026mu;\u003c/strong\u003e\u003cstrong\u003eL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9700\u0026plusmn;3800\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10600\u0026plusmn;4600\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.56\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCRP after admission (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.5\u0026plusmn;6.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.0\u0026plusmn;5.9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.549\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWBC after admission (\u003c/strong\u003e\u003cstrong\u003e\u0026mu;\u003c/strong\u003e\u003cstrong\u003eL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8150\u0026plusmn;3096\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8055\u0026plusmn;3320\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.91\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCre on admission (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.7\u0026plusmn;2.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.5\u0026plusmn;1.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.442\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eeGFR on admission (mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e55.1\u0026plusmn;26.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e59.9\u0026plusmn;29.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.256\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;CRP indicates C-reactive protein; WBC, white blood cell;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCre, creatinine; eGFR, estimated Glomerular Filtration Rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTables 5. Multivariate logistic regression analysis.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"565\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 297px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds ratio (95% confidence interval)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes mellitus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 297px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.83(1.17-12.5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEpidural abscess\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 297px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.79(1.24-11.6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 184px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompromised host\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 297px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.97(0.715-22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.115\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\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":"Pyogenic spondylitis, epidural abscess, diabetes mellitus, minimally invasive surgery, risk factors, surgical treatment","lastPublishedDoi":"10.21203/rs.3.rs-6540804/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6540804/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe frequency of pyogenic spondylitis has increased owing to an aging population and a growing number of immunocompromised patients. This study investigated risk factors for surgery in patients with pyogenic spondylitis treated at our hospital.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSeventy-one patients (52 males, 19 females) with pyogenic spondylitis treated from 2014 to 2023 were included. Conservative treatment was the primary approach, with surgery indicated for cases resistant to conservative management or with worsening neurological symptoms. Initial surgery involved minimally invasive stabilization, with debridement and anterior fixation performed when necessary. Age, sex, body mass index (BMI), fever rate, hospitalization duration, time to diagnosis, bacterial presence, blood tests, epidural abscess, immunocompromised status, and comorbidities were compared between the conservative and surgical treatment groups. Multivariate analysis identified risk factors for surgery.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNo significant differences were found in age, sex, BMI, fever rate, hospitalization duration, culture-positive rate, or blood tests. However, the prevalence of epidural abscess (36.6% vs. 60%) and diabetes mellitus (22% vs. 53.3%) was significantly higher in the surgical group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Epidural abscess (odds ratio: 3.79, P\u0026thinsp;=\u0026thinsp;0.0198) and diabetes mellitus (odds ratio: 3.83, P\u0026thinsp;=\u0026thinsp;0.0261) were independent risk factors in the logistic regression analysis.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study found no significant differences in inflammatory markers at admission or during hospitalization. Patients with epidural abscesses and diabetes mellitus were more likely to require surgery. Advances in minimally invasive surgery may have changed the risk factors for surgery compared with previous years.\u003c/p\u003e","manuscriptTitle":"Risk Factors for Surgical Treatment in the Management of Pyogenic Spondylitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-05 15:50:45","doi":"10.21203/rs.3.rs-6540804/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":"73107e10-0599-4a5e-a43b-18aa7a0428d7","owner":[],"postedDate":"June 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-01T18:08:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-05 15:50:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6540804","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6540804","identity":"rs-6540804","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}