Acta Neurochirurgica

https://doi.org/10.1007/s00701-023-05748-7

ORIGINAL ARTICLE

Surgical treatment of spondylodiscitis in critically ill septic patients

Shadi Al‑Afif1   · Oday Atallah1 · Dirk Scheinichen2 · Thomas Palmaers2 · Zafer Cinibulak1 · Jens D. Rollnik3 ·
Joachim K. Krauss1

Received: 18 May 2023 / Accepted: 3 August 2023

© The Author(s) 2023

Abstract
Purpose  Surgical procedures in critically ill patients with spondylodiscitis are challenging and there are several controversies.
Here, we present our experience with offering surgical intervention early in critically ill septic patients with spondylodiscitis.
Method  After we introduced a new treatment paradigm offering early but limited surgery, eight patients with spondylodiscitis
complicated by severe sepsis and multiple organ failure underwent urgent surgical treatment over a 10-year period. Outcome
was assessed according to the Barthel index at 12-month follow-up and at the last available follow-up (mean 89 months).
Results  There were 7 men and 1 woman, with a mean age of 62 years. The preoperative ASA score was 5 in 2 patients, and
4 in 6 patients. Six of them presented with high-grade paresis, and in all of them, spondylodiscitis with intraspinal and/or
paravertebral abscesses was evident in MR imaging studies. All patients underwent early surgery (within 24 h after admis-
sion). The median time in intensive care was 21 days. Out of the eight patients, seven survived. One year after surgery, five
patients had a good outcome (Barthel index: 100 (1); 80 (3); and 70 (1)). At the last follow-up (mean 89 months), 4 patients
had a good functional outcome (Barthel index between 60 and 80).
Conclusion  Early surgical treatment in critically ill patients with spondylodiscitis and sepsis may result in rapid control of
infection and can provide favorable long-term outcome. A general strategy of performing only limited surgery is a valid
option in such patients who have a relatively high risk for surgery.

Keywords  Critical ill patient · Sepsis · Spinal surgery · Spondylodiscitis · Early surgery

Introduction The clinical presentation of spondylodiscitis is highly

variable ranging from severe back pain to acute and life-
Spondylodiscitis is a heterogeneous but potentially life- threatening sepsis or rapidly progressive neurological defi-
threating condition which may cause a variety of neurologi- cits. Spondylodiscitis can either be the primary focus of
cal deficits [4, 29]. The estimated incidence in developed septicemia or result from septicemia originating from other
countries ranges between 4 and 24 per million [17, 48]. Its infection sources, such as pneumonia, urinary tract infection,
incidence has been increasing in the last four decades mainly endocarditis, or soft tissue abscesses [19].
secondary to the aging population in most countries world- Due to its close anatomical proximity to the spinal cord
wide [23, 42]. and cauda, spondylodiscitis can lead to severe neurologi-
cal deficits. This can occur through direct compression of
the spinal neural tissues or by causing instability through
* Shadi Al‑Afif destruction of the osseous and ligamentous spinal structures
al-afif.shadi@mh-hannover.de [19]. In such instances, urgent surgery has been advocated to
1 avoid persistent disability. In addition, spondylodiscitis may
Department of Neurosurgery, Hannover Medical School,
Carl‑Neuberg Str. 1, 30625 Hannover, Germany also be complicated by severe sepsis and multiple organ fail-
2 ure including heart failure, renal failure, severe pneumonia,
Department of Anaesthesiology and Intensive Care,
Hannover Medical School, Hannover, Germany respiratory insufficiency, or septic shock [8]. Many patients
3 who present with spondylodiscitis have a history of multi-
Institute for Neurorehabilitation Research (InFo),
BDH-Clinic Hessisch Oldendorf, Affiliated Institute ple co-morbidities which makes treatment challenging and
of Hannover Medical School, Hessisch Oldendorf, Germany which may have a negative impact on outcome.

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Medical treatment with antibiotics is the first choice in
most instances of spondylodiscitis [34]. Surgery is indi-
cated in patients with neurological deficits and involves
the decompression of neural structures, stabilization, and
re-establishment of spinal alignment, surgical source con-
trol with debridement of necrotic tissues, and drainage of
abscesses [4, 28].
Despite tremendous developments in surgical, anaesthe-
siological, and intensive care treatment in the last years, the
therapy of spondylodiscitis in critically ill patients is still
challenging and has been considered to be associated with
high morbidity and mortality [15]. Only few studies have
concentrated on surgical treatment in critically ill patients
with spondylodiscitis [7, 12, 18, 20]. There is even less expe-
rience with surgical treatment in critically ill patients with
spondylodiscitis and sepsis [18], since surgery often has
been thought to be contraindicated, and the subject is still
debated [32]. Nevertheless, more recent studies indicate that
mortality may be even higher in such patients solely having
conservative treatment [29]. Here, we report our experience
in offering early surgical treatment in critically ill patients
with spondylodiscitis and severe sepsis.
Methods
Since 2010, a new paradigm was introduced in the Depart-
ment of Neurosurgery at Hannover Medical School offer-
ing limited but early (within 24 h after admission) surgical
treatment including decompression, sanitation of the spinal
infection, and short segment stabilization when deemed
necessary also to critically ill patients with spondylodiscitis
developing sepsis regardless of age or the physical state as
determined by the American Society of Anesthesiologists
(ASA) score. Previously, such patients would have under-
gone medical treatment only and would have been offered
surgery only in case they would have stabilized and survived
sepsis.
Criteria to proceed with surgery was an unequivocal diag-
nosis of spondylodiscitis, rapid deterioration of the clini-
cal condition (despite antibiotic treatment), and the pres-
ence of neurological deficits. Contraindications for surgery
were accompanying active malignant diseases and severe
coagulopathies.
Acute respiratory distress syndrome (ARDS) was quan-
tified with the Horowitz index (H-Index) which evaluates
pulmonary function in ventilated patients by dividing
blood oxygen pressure (PaO2) by inhaled oxygen fraction
(FiO2) to calculate the PaO2/FiO2 ratio [3]. According
to the H-Index, ARDS is classified as mild (PaO2/FiO2
201–300 mmHg with PEEP ≥ 5 cmH2O), moderate (PaO2/
FiO2 101–200 mmHg with PEEP ≥ 5 cmH2O), or severe
(PaO2/FiO2 ≤ 100 mmHg with PEEP ≥ 5 cmH2O). When
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Acta Neurochirurgica
patients did not meet all criteria for ARDS, the term “res-
piratory insufficiency” was used.
For the present study, surgical and medical reports of
all spinal surgeries performed over a 10-year period were
screened to identify patients meeting the following criteria.
Inclusion criteria were as follows: (1) patients with clinical
manifestation of spondylodiscitis, epidural abscesses, and/
or paravertebral abscesses; (2) evidence of spondylodiscitis
and spinal infections on preoperative imaging studies; (3)
manifestation of severe sepsis that necessitated treatment
in the intensive care unit (ICU) with aggressive intravenous
catecholamine and fluid administration; and (4) patients who
underwent surgery early after admission with decompression
of neural structures, stabilization in case of biomechanical
instability, and/or source control of infection site. Exclusion
criteria were as follows: (1) patients with spondylodiscitis
without a need for ICU treatment, (2) patients with specific
spinal infections such as tuberculosis, and (3) patients who
had spondylodiscitis subsequent to prior spinal surgery.
The protocol of this retrospective study included review
of all available clinical and imaging data including docu-
mentation on the course of rehabilitation and supplementing
information on long-term outcome.
All patients underwent surgical treatment according to
standard departmental surgical techniques as described in
detail elsewhere [2, 9, 13, 44].
Clinical outcome was assessed by scheduled follow-up
examinations at 3 months and at 12 months after surgery
when possible. Further, information on recent follow-up
was obtained via structured telephone interviews with the
patients or their relatives. The performance in activities
of daily living and the degree of independence of patients
were evaluated using the Barthel index [30] with scores
of 0–20 indicating “total” dependency, of 21–60 “severe”
dependency, of 61–90 “moderate” dependency, and of 91–99
“slight” dependency.
Results
Eight patients were identified who fulfilled the inclusion and
exclusion criteria of the present study. There were 7 men
and 1 woman. Their age at surgery ranged between 53 and
78 years (mean age, 62 years). Seven had two or more co-
morbidities such as arterial hypertension, diabetes mellitus,
coronary heart disease, valvular heart disease, cardiomyopa-
thy, atrial fibrillation, pulmonary hypertension, and chronic
obstructive pulmonary disease (COPD) (Table 1). While
only two patients were primarily admitted to our tertiary care
center, the majority of patients (6 patients) were treated ini-
tially at other hospitals and were referred for further surgical
and medical/intensive care treatment.
 Table 1  Demographics and clinical data of 8 critically ill patients with spondylodiscitis and sepsis
Pat. No Sex Age Co-morbidities Main Symptoms Location/number Locations of CRP at Preoperative Empirical Preopera- Time interval
at presentation of segments with abscesses admission bacterial antimicrobial tive ASA- between admis-
spondylodiscitis (mg/L) isolation therapy score sion and surgery in
hours
Acta Neurochirurgica

1 M 64 HT, DM,CHD Sepsis, ARDS Lumbosacral/2 Epidural, paraspi- 129 Staphylococcus Piperacillin, 4 10
(H-index nal aureus in blood Meronem
120 mmHg), culture
paraparesis
2 M 53 HT, DM, recent Sepsis, endocar- Cervical/1 Epidural, paraspi- 177 Streptococcus Moxifloxacin, 4 17
THP-surgery, ditis, ARDS nal pneumonia in Meftriaxon,
adiposity (H-index blood culture Clindamycin
104 mmHg), and from knee
acute renal puncture
failure (anuria,
hyperkalemia:
6 mmol/l), tetra-
paresis
3 M 59 HT, CD Sepsis, respiratory Lumbosacral/1 Epidural, paraspi- 37 Staphylococcus Piperacillin, Dap- 4 21
insufficiency nal aureus in blood tomycin
with pneumonia, culture
acute renal
failure (anuria,
hyperkalemia:
5.5 mmol/l),
paraparesis
4 M 54 CHD, VHD, Sepsis, esophagus Thoracocervical/3 Epidural, paraspi- 137 - Clindmycin, 5 6
history of rupture and nal Piperacillin
lymphoma with mediastinitis,
cervical radia- ARDS (H-index
tion therapy 109 mmHg),
tetraparesis
5 M 57 Schizophrenia Sepsis, respiratory Cervical/3 Epidural, paraspi- 235 - Clindmycin, 4 5
insufficiency, nal Piperacillin
high grade tetra-
paresis
6 M 71 DCM, AF, CHD, Sepsis, acute Thoracic/1 Paraspinal 45 Staphylococcus Flocloxacillin, 4 19
VHD heart failure, aureus in blood Rifampicin
ARDS (H-index culture
113 mmHg),
acute renal
failure (anuria,
hyperkalemia:
5.8 mmol/l)

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 Acta Neurochirurgica

Preoperative medical and neurological course

disease, CM cardiomyopathy, AF atrial fibrillation, Hep. C hepatitis C, CKD chronic heart disease, PH pulmonary hypertension, COPD chronic obstructive pulmonary disease, THP total hip
ARDS acute respiratory distress syndrome, H-index Horowitz index, HT arterial hypertension, DM diabetes mellitus, CHD coronary heart disease, CRF chronic renal failure, VHD valvular heart
sion and surgery in
between admis-
Time interval
After admission to the ICU, all patients were treated with
continuous intravenous catecholamines and high-load intra-
venous fluids to maintain sufficient mean perfusion blood
hours

24

20
pressure. The ASA score before surgery was 5 in 2 patients
and 4 in 6 patients (Table 1).
tive ASA-
Preopera-

All 8 patients had respiratory problems, 4 of them with

the criteria of ARDS and 4/8 had multiple organ dysfunction
score

(Table 1). Three were intubated for mechanical ventilation,

4

Cefrtriaxon, Clin- 5
and the other 5 received non-invasive ventilation therapy.
In all patients, the c-reactive protein (CRP) was elevated
Clindamycin,
antimicrobial

(range 34–235 mg/L). After blood cultures had been taken,

Cefepim

damycin
Empirical

therapy

an immediate empirical antimicrobial treatment was initiated

within the first hour of admission in all instances. The anti-
biotic regimen included a wide spectrum of antibiotics cov-
aureus in blood

ering gram-positive and gram-negative bacteria (Table 1).

Staphylococcus
E. coli in blood

Blood cultures were positive in 6 patients (75%) identifying

Preoperative

the causal pathological organisms. In 5 instances, gram-pos-

culture

culture
bacterial
isolation

itive bacteria were found (Staphylococcus aureus (n = 4),

Streptococcus pneumonia (n = 1)), and in one patient, gram
stains were negative (E. coli). According to the microbio-
admission

logical results, the antibiotic treatment was adjusted in 4

CRP at

(mg/L)

patients. In 3 patients, primary infection sites were identi-

Epidural, paraspi- 128
Epidural, paraspi- 34

fied (Table 1) including (1) infected knee implant (patient

2), (2) perforated esophagus and mediastinitis after endo-
scopic esophageal dilatation with a history of prior radiation
Locations of

treatment of cervical lymphoma (patient 4, Fig. 1), and (3)

abscesses

endocarditis (patient 8).

nal

nal

Preoperative neurological examinations revealed severe

neurological deficits in 6 patients (Table 1) with paraparesis
(3 patients) and tetraparesis (3 patients). Two patients had
Location/number
of segments with
spondylodiscitis

intact motor functions.

Cervical/1
Lumbar/2

Preoperative imaging studies

Preoperative MRI with gadolinium confirmed spondylodis-

ditis, respiratory
failure (anuria,
Main Symptoms

Sepsis, endocar-

citis in all instances. Spondylodiscitis was located in the

hyperkalemia:
at presentation

124 mmHg),

insufficiency
Hep. C, AF, CKD, Sepsis, ARDS

6.7 mmol/l),
paraparesis
acute renal

cervical spine in 3 patients, in the thoracocervical spine in

(H-index

one, in the thoracic spine in another one, and in the lum-

bosacral spine in 3 patients (see Figs. 1 and 2). All patients
had epidural infections with compression of the spinal cord,
cauda, or spinal nerves in addition to paravertebral abscesses
DM, AM, CHD,
VHD, adiposity
HT, PH, COPD,
Pat. No Sex Age Co-morbidities

(Figs. 1 and 2).

Surgical treatments
CRF

The surgical treatment strategy was adopted individually

Table 1  (continued)

prosthesis surgery

according to the medical and surgical circumstances in every

78

58

patient. Preoperative correction of arterial hypotension and

M
F

coagulation parameters was achieved in all patients. The

time interval between admission and surgery for each patient
is outlined in Table 1.
7

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Acta Neurochirurgica
Fig. 1  A 57-year-old man presented with progressive tetraparesis
and severe sepsis. Sagittal and axial MRI (T1-weighted with gadolin-
ium) shows cervical spondylodiscitis and an intraspinal longitudinal
abscess with compression of the spinal cord (a, b). Emergency sur-
gery was performed including ventral discectomy, decompression of
Fig. 2  A 54-year-old man with tetraparesis and septic shock. Sagittal
MRI (T1-weighted with gadolinium) demonstrates multilevel spondy-
lodiscitis and massive prevertebral and epidural abscess in the lower
cervical segments (a). Postoperative CT after emergency surgery
including ventral corporectomy of C6 and C7, decompression of the
The surgical techniques which were applied included
the following: (1) dorsal interlaminar decompression and
drainage of epidural abscesses (2 patients); (2) cervical
corpectomy, drainage of epidural abscesses, and fusion
with autologous bone graft harvested from the iliac crest (2
patients) (Fig. 1); (3) anterior cervical discectomy, drain-
age of epidural abscesses, and fusion with PEEK-cage (2
patients) (Fig. 2); (4) dorsal laminectomy, drainage of epi-
dural abscess, and dorsal fixation with transpedicular screws
the epidural abscess, and insertion of intervertebral cages at 3 cervi-
cal levels (c). During ICU treatment and antibiotic therapy, the tetra-
paresis resolved completely, and the patient was discharged to reha-
bilitation
epidural and prevertebral abscess, and fusion with autologous bone
graft harvested from the ilium supplemented by plate osteosynthesis
(b). The tetraparesis resolved partially prior to discharge for rehabili-
tation
(1 patient); (5) transthoracic decompression of a prevertebral
abscess (1 patient).
The mean duration of surgery was 117  min (range
87–257  min). In one patient, an accidental durotomy
occurred (patient 1, Table 2), which was closed primarily
with stitches, without a cerebrospinal fistula postoperatively.
In patient 6, the surgery had to be stopped after drainage of
the prevertebral abscess. The initially planned dorsal stabi-
lization with pedicle screws was not possible due to severe
intraoperative cardiopulmonary decompensation.
13


Table 2  Surgical treatment and postoperative courses of 8 critically ill patients with spondylodiscitis and sepsis
Pat. No Surgery Time of Intraop- Bacterial Early (1–3 Adjust- Length of Postopera- Length of Length of Neuro- Neurologi- Barthel- Last follow
surgery in erative isolation day) post- ment of antimi- tive com- ICU stay hospital logical cal state index up in months

13
minutes complica- obtained operative the anti- crobial plications (days) stay before outcome at (12 (12 after surgery
tions from CRP microbial treatment in ICU rehab discharge months months / Barthel-
surgery treatment in days: iv/ (days) after after index at last
oral (total surgery) surgery) follow-up
period)

1 Dorsal 205 Dural Staphylo- 83 Clinda- 15/33 - 3 17 Improve- Improve- 70 174/50

lumbar, injury coccus mycin, (48) ment of ment of
inter- aureus Flucloxa- parapare- parapare-
laminar cillin sis from sis with
decom- grade 0/5 residual
pression, to 3/5 footpare-
and drain- sis (4/5)
age of the
epidural
abscesses
2 Anterior 292 - - 168 Vanco- 87/30 Endocar- 33 42 Improve- No neuro- 100 48/ died 48
cervical mycin, (117) ditis, ment of logical months
discec- Mero- pneumo- tetra- deficits after sur-
tomy, nem nia, renal paresis gery due
drainage failure, from to heart
of the septic grade 1/5 infarction
epidural encepha- to 4/5
abscesses, lopathy
and fusion
using
PEEK-
cage
3 Dorsal lum- 150 - - 61 Cephazo- 32/31 - 5 5 Improve- Mild gait 80 155/70
bar lami- lin (63) ment of ataxia
nectomy, parapare-
drainage sis from
of epidural grade 1/5
abscesses, to 3/5
and dorsal
fixation
via trans-
pedicular
screws
Acta Neurochirurgica
 Table 2  (continued)
Pat. No Surgery Time of Intraop- Bacterial Early (1–3 Adjust- Length of Postopera- Length of Length of Neuro- Neurologi- Barthel- Last follow
surgery in erative isolation day) post- ment of antimi- tive com- ICU stay hospital logical cal state index up in months
minutes complica- obtained operative the anti- crobial plications (days) stay before outcome at (12 (12 after surgery
tions from CRP microbial treatment in ICU rehab discharge months months / Barthel-
surgery treatment in days: iv/ (days) after after index at last
Acta Neurochirurgica

oral (total surgery) surgery) follow-up

period)

4 Cervical 230 - Strepto- 257 - 21/41 Recon- 28 28 Improve- Tatrapare- 15 15/ died 15
corpec- coccus (62) struc- ment of sis 3/5 months
tomy, angi- tion of tetra- after sur-
drainage nosus, esopha- paresis gery due to
of the Lacto- gus after from pulmonary
epidural bacillus rupture grade 0/5 embolism
abscesses, rham- to 3/5
and fusion nosus,
with bone Candida
graft dublin-
harvesting iensis,
from iliac Staphy-
crest lococcus
warner
5 Anterior 166 - Staphylo- 64 Clinda- 49/44 - 9 17 Improve- Tetrapare- 20 24/ died
cervical coccus mycin, (93) ment of sis 3/5 24 months
discec- aureus Flucloxa- tetra- after sur-
tomy, cillin paresis gery due
drainage from to heart
of the grade 1/5 infarction
epidural to 3/5
abscesses,
and fusion
using
PEEK-
cage
6 Transtho- 154 Severe car- - 196 - 32/46 Acute 41 42 No neuro- No neuro- 80 98/60
racic diopul- (78) pulmo- logical logical
decom- monary nal and deficits, deficits
pression dete- cardial tracheos-
of a pre- rioration, worsen- toma
vertebral surgery ing
abscess must be
aban-
doned

13


Table 2  (continued)
Pat. No Surgery Time of Intraop- Bacterial Early (1–3 Adjust- Length of Postopera- Length of Length of Neuro- Neurologi- Barthel- Last follow
surgery in erative isolation day) post- ment of antimi- tive com- ICU stay hospital logical cal state index up in months

13
minutes complica- obtained operative the anti- crobial plications (days) stay before outcome at (12 (12 after surgery
tions from CRP microbial treatment in ICU rehab discharge months months / Barthel-
surgery treatment in days: iv/ (days) after after index at last
oral (total surgery) surgery) follow-up
period)

7 Dorsal lum- 170 - - 42 - 36/65 Reanima- 40 40 Improve- No neuro- 80 110/80

bar inter- (101) tion, ment of logical
laminar pneu- parapare- deficits
decom- monia. sis from
pression second grade 1/5
and drain- revision to 4/5
age of the surgery
epidural due to
abscesses recur-
rance of
epidural
abscess
8 Cervical 295 - Staphylo- 66 Vanco- 24/33 Replace- 11 107 Exitus - - -
corpec- coccus mycin, (57) ment of letalis
tomy, aureus Mero- mitral due to
drainage nem valve, multiple
of the emer- organ
epidural gency failure
abscesses revision
and fusion surgery
with bone for hema-
graft tothorax,
harvesting pneumo-
from iliac nia
crest
Acta Neurochirurgica
Acta Neurochirurgica
Postoperative course and outcome
In the two patients with negative blood cultures, the micro-
biological cultures of samples obtained during surgery could
identify the nature of the microorganisms. A second revision
surgery was necessary for one patient due to recurrence of
the epidural abscesses (patient 7, Table 2).
All patients were stabilized in the ICU postoperatively
(median stay 21 days; range 3–41 days). The early post-
operative course was complicated in 4 patients, and two of
them underwent further secondary surgeries (reconstruction
of a ruptured esophagus by ENT surgeons in patient 4 and
replacement of a mitral valve and revision of thoracic hema-
toma in patient 8).
The duration of the antimicrobial therapy was adjusted
according to the clinical course. Intravenous antibiotics were
given at least for 2 weeks in all patients (median time intra-
venous treatment 37 days, range 15–87 days). The overall
period of antibiotic treatment (intravenous and oral) was
11 weeks (range 48–117 days) (Table 2).
One patient passed away due to complications related to
endocarditis on day 107 after spinal surgery. Seven patients
survived and were referred to rehabilitation. At discharge,
two had a tracheostomy and needed supportive ventilation.
All 6 patients with motor deficits improved before referral
to rehabilitation.
One year after surgery, five patients (70%) had achieved
marked benefit (Barthel index: 100 (1 patient), 80 (3
patients), and 70 (1 patient). Two patients still needed inten-
sive ambulatory care (Barthel index, 15 and 20, respectively)
(Table 2). The mean long-term follow-up was 89 months
(range 15–174  months). The distribution of the Barthel
index with a favorable outcome ranged between 60 and 80
in four patients, and one patient had died due to myocardial
infarction unrelated to septic spondylodiscitis (Table 2). The
two patients who had a low Barthel index at 1-year follow-
up, died later due to myocardial infarction and pulmonary
embolism (15 and 24 months after surgery, respectively)
(Table 2).
Discussion
Our study shows that early surgical treatment in critically
ill patients with spondylodiscitis and sepsis offers several
advantages, and it may result in both rapid control of infec-
tion and favorable long-term outcome with improvement of
neurological deficits in the majority of patients. While in the
past, such patients often were not considered candidates for
immediate surgery [38]; there has been a gradual change in
opinion resulting in a call for earlier and more aggressive
surgical treatment [29]. Such an approach is particularly jus-
tified, since the cause of death in the population under study
has been primarily related to worsening of sepsis and sub-
sequent progression of disease [29, 45]. In a previous study
on spondylodiscitis, the number of deaths was significantly
higher in patients with conservative treatment then in those
who underwent early surgery. Remarkably, 59% of reported
deaths were attributed to septic multiple organ failure [29].
We suggest that our study will further stimulate to consider
a change of paradigm.
In a previous study on offering early surgery to patients
with septic hematogenous lumbar spondylodiscitis in elderly
patients by operative decompression and eradication of the
intraspinal and intervertebral infective tissue with fusion via
a posterior approach, there was a perioperative mortality
of 17% and a morbidity of 50% [18]. With regard to their
relatively high morbidity, the authors concluded that surgi-
cal treatment should not be the therapy of first choice in
highly septic patients, but it may be considered when con-
servative management has failed [18]. While postoperative
mortality was comparable in our study, morbidity was much
lower when adopting a more flexible and limited surgical
approach.
The complication rate in our study is comparable to
another previous study on early surgery for spondylodis-
citis [41]. In this study, 2 patients succumbed due to septic
shock associated with endocarditis [41]. However, it was
not specified how many patients overall presented with sep-
sis at the time of surgery. Remarkably, in our study in only
one patient, surgery had to be aborted after decompression
and before planned stabilization because of intraopera-
tive anaesthesiological problems despite high preoperative
ASA grades in all instances. In that case, the transthoracic
approach certainly contributed as an additional risk factor.
Risk factors for the development of sepsis in patients with
spondylodiscitis include advanced age, diabetes mellitus,
renal failure, and an immunocompromised health state [1,
47]. In our study, the majority of the critically ill patients had
a history of 2 or more co-morbidities. Using a large Japanese
database, Akiyama et al. could identify an overall in-hospital
mortality rate of 6% in patients with spondylodiscitis, but
it was significantly higher in patients on hemodialysis (OR,
10.56), diabetes (2.37), liver cirrhosis (2.63), malignancies
(2.68), and infective endocarditis (1).
The identification of the causal pathogenic organisms is
one of the most important steps in the treatment of spon-
dylodiscitis and sepsis. Blood cultures before initiation of
antibiotic treatment have been advocated. The sensitivity
of blood cultures ranges between 30 and 78% [33]. In our
study, blood cultures yielded a diagnosis in 75% of cases.
This result more likely is due to the higher sensitivity of
blood cultures in patients with fever and septicemia [22].
In two patients with negative blood cultures, however, the
causal pathological organisms could be identified only from
samples from the surgical site. In our study, in 3 patients,
13

the sepsis resulted from extraspinal infection sites, but the
source of sepsis was not identified in the other patients.
While the cause for infection of the spine remained unclear,
the spondylodiscitis itself might have been the source for the
worsening of the sepsis [28].
Comparable to the treatment of sepsis in other infectious
disorders, the treatment principles of septic spondylodiscitis
involve early administration of broad-spectrum antibiotics
and maintenance of the cardiovascular circulation to obtain
an adequate perfusion pressure [6, 37]. With that regard, all
patients in our study received empirical broad-spectrum anti-
biotics immediately after obtaining blood cultures. Whereas
the antibiotic treatment in patients with uncomplicated spon-
dylodiscitis can be postponed until obtaining a sample from
the infection site (surgically or CT-guided), in septic spondy-
lodiscitis, the administration of antibiotics should be started
within 1 h to reduce the mortality rate [37]. Since the course
of sepsis may be complicated by multiple organ dysfunction,
early referral to the ICU to allow mechanical ventilation and
dialysis is pivotal [5, 27].
Another aspect to consider in the treatment of sepsis
is the source control of the bacterial spread [31], which is
mainly performed surgically. In general surgery, the tim-
ing of surgery for source control in unstable patients with
severe sepsis due to different etiologies is controversial
[46]. Although some authors postulate that patients initially
should stabilize medically and then undergo surgery [32],
the majority of studies and guidelines argue for early source
control [37, 40, 43].
The extent of surgical treatment for infectious spondy-
lodiscitis has been discussed controversially [18]. Different
surgical approaches have been reported ranging from mini-
mally invasive approaches without fusion and instrumenta-
tion such as percutaneous or endoscopic suction aspiration
and drainage [21, 35] to more aggressive surgical procedures
[11, 14, 24]. More extensive surgeries have included poste-
rior instrumentation combined with anterior bone grafting
or insertion of cages [11, 16, 25], anterior approaches with
bone grafting [24] combined with anterior instrumentation
[14], posterior approaches and instrumentation with discec-
tomy and interbody bone grafts [26, 36], and eradication of
the infected tissue and interbody fusion [10]. Additionally,
both one-stage and two-stage dorsoventral operations were
described in previous studies [16, 25, 39].
Limitations of our study are its retrospective nature, the
relatively low number of patients, and lack of a (historical)
control group, while its strengths include a defined surgical
treatment paradigm (early surgery) and a long follow-up in
all patients without attrition.
While our study was not designed to investigate the
superiority of a certain surgical approach (decompression
only versus additional stabilization), it shows that a general
13
Acta Neurochirurgica
strategy of performing only limited and the least possibly
invasive surgical treatment is a valid option in this fragile
population of critically ill patients who have a relatively high
risk for surgery.
Funding  Open Access funding enabled and organized by Projekt
DEAL.
Data Availability  Data is available upon reasonable request.
Declarations 
Ethics approval and Consent to Participate  All procedures performed
in studies involving human participants were in accordance with the
ethical standards of Hannover Medical School and with the 1964 Hel-
sinki declaration and its later amendments or comparable ethical stand-
ards. Informed consent was obtained from all individual participants
or their relatives included in the study.
Conflict of Interest  The authors declare no competing interests.
Open Access  This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
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