Der Orthopäde
Übersichten
Orthopäde 2020 · 49:482–493
https://doi.org/10.1007/s00132-019-03836-0
Published online: 13 November 2019
© Springer Medizin Verlag GmbH, ein Teil von
Springer Nature 2019
Introduction
Pyogenic spondylodiscitis (PS) encom-
passes osteomyelitis of the vertebra and
intervertebral discs [1]. A multitude of
terms are used to describe the same debil-
itating condition, such as septic discitis,
spinal osteomyelitis, disc space infection
and vertebral osteomyelitis [1, 2]. The
PS has far-reaching clinical implications
for patients by increasing disability re-
flected in lower health-related quality of
life (HRQoL) scores [3]. It could result
in septicemia, irreversible spinal cord in-
jury, neurologic deficits, has a mortality
which of 4–29% [4, 5] and spinal de-
formity with debilitating complications
as a result of prolonged vertebral disc
destruction from chronic infections [6].
The PS primarily impacts older people
with underlying comorbidities, such as
diabetes, heart disease, immunosuppres-
sive disorders, use of intravenous drugs,
renal failure necessitating hemodialysis
and cancer [1, 7, 8]. The incidence of
PS has been documented at 2.4 cases per
100,000 population and increases with
age (from 0.3 per 100,000 among patients
under 20 years of age to 6.5 per 100,000
among patients older than 70 years) [1,
9]. It has also been shown that it could
affect any age group. Some studies have
reported a bimodal age distribution with
peaks in patients whose age is less than
20 years and in the group of patients aged
over 50 years [1, 10, 11]. It mainly af-
fects males with a male to female ratio
of 1.5–2:1 [1, 10, 11]. An increase of
PS incidence in Europe and the USA has
The manuscript does not contain information
about medical device(s)/drug(s).
482 Der Orthopäde 6 · 2020
H. Almansour · W. Pepke · M. Akbar
Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury, Heidelberg University,
Heidelberg, Germany
Pyogenic spondylodiscitis
The quest towards a clinical-radiological
classification
been also documented. This could be ex-
plained byincreased life expectancyofthe
general population and of patients with
predisposing comorbidities as well as the
rising number of spinal surgeries and im-
proved diagnostic methods [2, 11]. The
routes of PS infections include hematoge-
nous seeding, contiguous spreading from
neighboring soft tissue infections and
from direct inoculation in the context
of spine surgery [1, 12]. Staphylococcus
aureus is the most common non-tubercu-
losis pathogen incriminated in PS. In the
context of postspinal fusion PS, the main
causative pathogens are coagulase-nega-
tive staphylococci and Cutibacterium ac-
nes [1, 10, 12]. In the setting of chronic
bacteremia, low-virulence bacteria, such
as coagulase-negative bacteria [1, 13] are
implicated. The avascular nature of the
intervertebral disc provides a safe milieu
for bacterial seeding. Moreover, bacte-
rial seeding at the arterioles of vertebral
endplates paves the way for an increased
intraosseous pressure which contributes
to lower blood flow in the infected re-
gion [6, 14]. Hence, prolonged antibiotic
treatment for PS is warranted to eradi-
cate the infection [6, 14]. In a multicenter
study of 253 patients with PS, McHenry
et al. delineated the primary source of
infection. The predominant infection fo-
cus was urinary tract, skin, or soft tissue
infection such as endocarditis or septic
arthritis or an intravenous access [1, 12].
Symptomatology of PS is insidious [1].
The most common initial clinical feature
is back pain and the location correlates
with the site of infection [1]. Exacerba-
tion of pain at night could be considered
an warning sign; however, it was reported
that up to 15% of patients did not experi-
ence pain at initial presentation [15]. In
a systematic review and meta-analysis on
PS, Taylor et al. showed that the lumbar
spine is the most common site of infec-
tion followed by the thoracic spine and
the cervical spine [6]. Radiculopathy or
sharp back pain could indicate the pres-
ence of an epidural abscess [16]. Spinal
tenderness on percussion is considered
the most common sign elicited on clinical
examination [17]. Fever is not uniformly
reported. In one case series, fever was
reported in 8 patients out of 59 [17].
This could be because analgesic medica-
tions are administered [1]. Neurological
deficits such as motor or sensory loss as
well as loss of sphincter control are also
commonly associated with PS [18]. Di-
agnosing PS remains challenging due to
its insidious course and high incidence
and prevalence of back pain in the gen-
eral population [1]. Healthcare providers
should exercise a high index of suspicion
of this condition and should apply sound
clinical judgement on the basis of clini-
Abbreviations
ASIA American Spinal Injury Association
CRP C-reactive protein
CT Computed tomography
ESR Erythrocyte sedimentation rate
HRQoL Health-related quality of life
IDSA Infectious Disease Society of
America
MRI Magnetic resonance imaging
PS Pyogenic spondylodiscitis
ROM Range of motion
SEA Spinal epidural abscess
cal manifestation, laboratory results and
imaging characteristics [1, 4]. In the light
of the broad differential diagnosis of low
back pain even in the context of a febrile
patient with neurologic deficits, many PS
diagnoses are missed. A delay in the di-
agnosis of almost 2 months has been re-
ported [19]. For example, the initial diag-
nosis of PS in a study of 109 patients with
Staphylococcus aureus bacteremia was ac-
curately done in only 5% [15, 20]. Even in
cases of correct diagnosis, management
is still controversial. Many classification
systems and algorithms of management
have been reported [11, 21, 22]; how-
ever, these systems could be considered
too complex and immature to reach con-
sensus. The Infectious Diseases Society
of America (IDSA) published the first
guidelines on antibiotic treatment of PS
and paved the way for more standardized
treatment [4]; however, in the absence of
a straightforward, evidence-based surgi-
cal classification of PS, the management
approach is still too complex, controver-
sial and is reliant on the best judgment
of the surgeon.
The aim of this paper was to review
the most recent classification systems and
critically appraise the classification cri-
teria suggested to healthcare providers
when faced with a case of PS.
Material and methods
Search methodology
An advanced PubMed search of titles ab-
stracts was conducted utilizing the terms
Classification AND Spondylodiscitis OR
septic discitis OR spinal osteomyelitis OR
vertebral osteomyelitis OR vertebral in-
fection OR spinal infection. No filters
pertaining to language of publication or
date of publication were applied. The bib-
liographies of the relevant papers were
retrieved and manually scanned for rele-
vance. Furthermore, systematic reviews
on the different criteria for classifying PS
were manually searched and discussed.
Results
A total of 43 articles were retrieved com-
prising 23 retrospective case series, 5 re-
views, 2 letters to the editor and 1 case
report: 7 papers whose main focus was
back pain and not spondylodiscitis were
excluded. In total, three major classi-
fication systems were proposed in the
literature. These classifications were de-
signed to encompass the most important
clinical, anatomical and biomechanical
factors essential to decide the next best
step in management.
In total five criteria were proposed:
1. Neurological deficits
2. Abscess formation
3. Segmental instability
4. C-reactive protein (CRP)
5. Pain
6. MRI morphological findings.
PS classification systems
Akbar et al. developed a classification of
PS based on a retrospective clinical and
radiological analysis of 221 patients who
underwent surgical treatment [21]. They
concluded that spondylodiscitis without
significant bone destruction, deformity
or neurologic deficits should be treated
with immobilization and antibiotic ther-
apy and that treatment should be dictated
by the extent of the inflammation. Fur-
thermore, they argued that that choice of
surgical approach should be performed
according to the philosophy of the spine
center. Criteria for surgical treatment en-
compassed intractable pain, abscess for-
mation, neurological status and spinal
instability with segmental kyphosis of
more than 25° and vertebral compres-
sion fracture. As a result, 7 subtypes
were proposed:
Type 0. No neurologic deficits, no ab-
scess formation and no bony destruc-
tion. Treatment of choice is immobi-
lization with an orthosis and antibiotic
treatment.
Type 1 A. No neurologic deficits. This
type encompassed cases with psoas ab-
scess without vertebral or disc involve-
ment. Treatment of this subtype was CT-
guided drainage of abscess or surgical de-
bridement and drainage depending on
the size of the abscess.
Type 1 B. Patients who presented with
neurologic deficits and encompassed
cases with epidural abscess formation
without vertebral or disc involvement.
Treatment of this subtype was posterior
decompression via hemilaminectomy
and drainage of epidural abscess.
Type 2. Patients with a physiological
sagittal alignment but with neurologic
deficits and epidural abscess with ver-
tebral disc involvement. Treatment of
choice is decompression, stabilization
and vertebral body replacement via cage
implantation.
Type 3. Includes patients withabscess for-
mation without specification of abscess
type. Furthermore, this type includes
cases with compression fracture of less
than 50% of the vertebral body and seg-
mental kyphosis of less than 25°. De-
pending on the neurological symptoms,
this type is subclassified into A) no neu-
rologic deficits and B) with neurologic
deficits. Treatment of choice was an-
terior debridement with vertebral body
replacement and stabilization for type A
and posterior decompression and stabi-
lization for type B.
Type 4. includes cases with more severe
spinal deformation encompassing com-
pression fracture of more than 50% and
segmental kyphosis with abscess forma-
tion with or without neurologic deficits.
Treatment of this type included decom-
pression anterior and posterior stabiliza-
tion
Furthermore, Akbar et al. modified
their classification to include spondy-
lodiscitis of the cervical spine [23]. Simi-
larly, type 0 is without abscess formation
or bony destruction. The treatment of
choice is a cervical brace and immobi-
lization and antibiotic treatment. Type 1
includes cases with neurologic deficits,
epidural abscess and vertebral disc in-
volvement; however, patients with type 1
have a physiological sagittal profile with
no bony destruction or deformity. The
treatment of choice is anterior or pos-
terior decompression and stabilization.
Type 2 includes cases with bony destruc-
tion and segmental kyphosis with neuro-
logic deficits (type 2A) or without neu-
rologic deficits (type 2B). If the case was
monosegmental or bisegmental spondy-
Der Orthopäde 6 · 2020 483
 Abstract · Zusammenfassung
Orthopäde 2020 · 49:482–493 https://doi.org/10.1007/s00132-019-03836-0
© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019
H. Almansour · W. Pepke · M. Akbar
Pyogenic spondylodiscitis. The quest towards a clinical-radiological classification
Abstract
Background. Pyogenic spondylodiscitis (PS) is
a debilitating condition laden with orthopedic
and neurological complications. The choice of
the best step in management is often delayed
due to the controversy encompassing its
multiple facets. Several classification systems
were proposed in the literature to define
optimal management; however, consensus
was not achieved.
Objective. The aim of this study was to review
the literature and critically appraise the
classification systems of PS and the rationale
behind the classification criteria.
Methods. A literature search was conducted
in PubMed. Titles and abstracts of articles
were searched using different synonyms of
Pyogene Spondylodiszitis. Die Suche nach einer klinisch-radiologischen Klassifikation
Zusammenfassung
Hintergrund. Die pyogene Spondylodiszitis
(PS) ist eine lebensbedrohliche Erkrankung
mit zahlreichen orthopädischen und
neurologischen Komplikationen. Die Wahl
des besten Therapieschrittes wird aufgrund
der facettenreichen Darstellung des Krank-
heitsbilds häufig verzögert. In der Literatur
wurden mehrere Klassifikationssysteme zur
Entscheidungsfindung vorgeschlagen, um
ein optimales Therapie-Management zu
definieren. Ein Konsens wurde jedoch nicht
erreicht.
Fragestellung. Das Ziel dieser Studie ist es,
die Literatur bezüglich der vorhandenen
Klassifikationen der PS zu überprüfen und
die Klassifizierungsparameter kritisch zu
bewerten.
Methoden. Eine Literaturrecherche wurde
mit PubMed durchgeführt. Titel und Abstracts
von Artikeln wurden mit verschiedenen
Synonymen der Spondylodiszitis und
lodiscitis (one vertebra), the treatment of
choice was anterior decompression with
vertebral body replacement. If the infec-
tion was multisegmental, then posterior-
anterior instrumentation with vertebral
body replacement was chosen. Similarly,
Pola et al. [11] recently suggested a clini-
coradiological classification encompass-
ing the most important prognostic factors
in the sphere of PS: neurologic deficits,
segmental instability and abscess forma-
484 Der Orthopäde 6 · 2020
spondylodiscitis and its classification. No
restrictions regarding language of publication
or date of publication were applied.
Results. A total of 43 papers with 5 encom-
passing 3 main classifications were found
in the literature. These classifications were
overlapping but different. They encompassed
neurologic deficits, abscess formation and
segmental instability, laboratory parameters
and morphological changes in magnetic
resonance imaging (MRI) as the most
important factors used to classify PS, assess
the severity and guide treatment.
Conclusion. The current classification schemes
overlap and encompass the most clinically
relevant factors; however, some could be
ihrer Klassifikation durchsucht. Sowohl
die Veröffentlichungssprache als auch
das Veröffentlichungsdatum stellten kein
Ausschlusskriterium dar.
Ergebnisse. Iinsgesamt wurden 43 Artikel
gefunden, von denen 5 Arbeiten 3 ver-
schiedene Klassifikationen aufwiesen. Diese
Klassifikationen überschneiden sich, auch
wenn sie sich zum Teil unterscheiden. Sie
umfassen die wichtigsten Parameter wie das
neurologische Defizit, die Abszessbildung und
die segmentale Instabilität sowie Laborpara-
meter und morphologische Veränderungen
in der Magnetresonanztomographie (MRT)
zur Klassifizierung der PS, zur Einschätzung
des Schweregrades und zur therapeutischen
Entscheidungsfindung.
Schlussfolgerungen. Die aktuell publizierten
Klassifikationen zeigen bezüglich des
Aufbaus Überlappungen und umfassen die
klinisch relevantesten Parameter. Einige
tion. It was divided into three types A, B,
and C which were then subdivided into
a total of 11 subtypes:
Type A. Cases with biomechanical insta-
bility without abscess or neurological im-
pairment. Divided into A1–A4, ranging
from simple discitis to bilateral intra-
muscular abscesses. Management of this
type ranged from using a rigid orthosis
to percutaneous stabilization.
too complex for interdisciplinary clinical
practice and do not adequately address
unique entities, such as PS of the cervical
spine, anterolisthesis and retrolisthesis. Most
importantly, some criteria must be utilized in
concert with recently published guidelines
and should be re-assessed for validity and
reliability. A uniform orthopedic parlance is
required to optimize the management of this
debilitating and life-threatening condition.
Keywords
Vertebral osteomyelitis classification ·
Surgery · Neurologic deficits · Epidural
abscess · Segmental instability
dieser Klassifikationen könnten jedoch
für die interdisziplinäre klinische Praxis zu
komplex und im klinischen Alltag schwere
zu handhaben sein. Auch werden einzelne
Entitäten wie z. B. die PS der Halswirbelsäule,
die Antero- und die Retrolisthese nicht
adressiert. Am wichtigsten ist, dass einige der
enthaltenen Kriterien in Übereinstimmung
mit den kürzlich veröffentlichten Leitlinien
verwendet werden müssen und auf ihre
Validität und Reliabilität überprüft werden
sollten. Eine einheitliche orthopädische
Klassifikation ist erforderlich, um das
Management dieser lebensbedrohlichen
Erkrankung zu optimieren.
Schlüsselwörter
Klassifikation · Operative Therapie · Neurologi-
sche Defizite · Epiduraler Abszess · Segmentale
Instabilität
Type B. Included cases withbonydestruc-
tion or instability without neurological
impairment or abscess formation. This
type was further divided into B1–B3
and included cases with bony destruc-
tion without instability, cases with bony
destruction with paravertebral exposure
and bony destruction with segmental
kyphosis. Segmental instability was de-
fined as a segmental kyphosis of more
than 25°. Management of this type
ranged from rigid orthosis and immo-
bilization to open stabilization.
Type C. Encompassed cases with acute
neurological impairment or formation
of an epidural abscess. It was subdivided
into four classes (C1–C4). The worst case
scenario was classified as C4 with pres-
ence of an epidural abscess, acute neu-
rological impairment and segmental in-
stability whose management ranged from
rigid orthosis immobilization to open de-
bridement and stabilization.
Finally, Homagk et al. [22] intro-
duced the spondylodiscitis severity score
(SSC) and classified PS cases of the tho-
racic and lumbar spine into three grades
of severity depending on clinical and
neurological status, morphological ver-
tebral destruction and instability. Each
severity grade is subclassified if neighbor-
ing tissue was involved in the inflamma-
tion (A) or not involved (B). They sug-
gested conservative treatment only for
a low-grade spondylodiscitis (grade 1)
and patients whose comorbidities pro-
hibit surgery [22]. Henceforth, six sub-
types were proposed:
4 Severity grade I A/B: no neurologic
deficits or segmental instability or
spinal canal stenosis. The tratment
of choice is conservative or posterior
stabilization.
4 Severity grade II A/B: no neurologic
deficits with segmental instability and
kyphosis due to vertebral destruction.
The treatment of choice is posterior
stabilization in the thoracic and
lumbar spine. After a 3-month
interval, the necessity of anterior
stabilization was determined on CT
scans to check for anterior fusion.
4 Severity grade III A/B: all cases
with neurologic deficits regardless of
other factors. Treatment of choice is
immediate two-staged stabilization
surgery with a short interval.
Homagk et al. then modified the SSC
to spondylodiscitis diagnosis and treat-
ment (SponDT) based on three charac-
teristics: CRP, pain and MRI morpho-
logical changes [24]. The score is used
to stratify the severity of PS. It ranges
from 0 to 9. Scores under 3, 3–6 and
over 6 are classified as light, moder-
ate and severe spondylodiscitis, respec-
tively. Each category is given 3 points,
CRP is given 0, 1, 2 and 3 points when
CRP (mg/dl) is under 10, between 10–50,
between 51–150 and over 150, respec-
tively. Pain on a numerical rating scale
is given 0, 1, 2 and 3 points when pain is
under 3, between 3–5, between 3–8, and
over 8, respectively. The MRI morpho-
logical changes are given 0, 1, 2 and 3
points when there are no MRI changes
indicating PS, when there is a spondylitis
or discitis, when there is spondylodisci-
tis, and when there is spondylodiscitis
with abscess formation, respectively. In
contrast to the other static classification
schemes, they developed a dynamic eval-
uation score which could be utilized to
modify treatment according to disease
progression.
Discussion
Principles and rationale behind the
genesis of a PS classification
A clinically relevant classification should
accurately delineate all potential varia-
tions of PS, assist in the documentation,
enable an efficient lingua franca among
international peers and assign clear steps
in management. Most importantly, it
should be able to prognosticate different
treatment outcomes [25]. Development
of a classification is not a static process but
a dynamic continuum requiring multi-
ple recalibrations and modification until
it gains acceptance of the international
community [26]. Mirza et al. summa-
rized the principles underlying an ideal
classification system. These include fac-
tors such as identification, comprehen-
siveness, inclusiveness, concise and de-
scriptive terminology, treatment guid-
ance and ability to predict outcomes [26].
The Institute of Medicine stated that the
following factors are critical to the de-
velopment of sound treatment guidelines
such as: validity, reliability, reproducibil-
ity, clinical applicability, clinical flexi-
bility, clarity, multidisciplinary process,
review of evidence, and documentation
[27]. It is of note, that there is no per-
fect classification that could encompass
the wide spectrum of individual cases
and cover all variations and comorbidi-
ties of patients which have a pivotal role
in deciding the right treatment [25, 26];
however, this should not stand as an ob-
stacle in the way of developing a common
language that clinicians can utilize as ori-
entation, a lingua franca that is easy to
handle and would be a part of the medi-
cal parlance in terms of spondylodiscitis
[25, 26].
Limitations of the current
classification systems
Current classification systems lack im-
portant factors which could be consid-
ered pivotal for the next evolutionary
step of a PS classification. The reli-
ability of these classification has not
been tested. A classification should be
considered a measurement instrument
whose inter-rater and intra-rater relia-
bility should be tested [28]. Moreover,
a sound psychometric evaluation of these
classifications has not been performed.
These classifications were developed as
an expert opinion and retrospectively
validated on a patient series in a single
center. Hence, an objective validation
did not occur. Content validity was also
not tested. This is type of validity that
examines the extent to which diagnostic
parameters of the severity measure make
intuitive sense [26]. Consensus building
approaches such as the Delphi surveys
were not conducted and hence no content
validity of the classification criteria could
be established [26]. This introduces an-
other limitation that these classifications
although somehow overlapping lack
“globality”. Mirza et al. defined globality
as the ability of a classification system
to transcend a single describing author’s
vision and hold a consistently mean-
ingful application to interested parties
outside an organizational or geographic
philosophy [21, 26]. Neurologic deficits,
abscess formation and segmental in-
stability are generally accepted criteria
[29]; however, the minute details used
to stratify patients should be validated
in a multicenter study.
Der Orthopäde 6 · 2020 485
 Übersichten

Fig. 1 8 a–k Different scenarios of abscess formation. a, c, e and g Schematic representations of a vertebra showing the spinal
canal and the spinal cord (blue) and the psoas muscle (brown). Paraspinal abscess and epidural abscess are shown (red). b, d,
fandh Axial MRIimages showingparaspinal andepidural abscesses.iSagittal schematic representationofthe spine depicting
an epidural abscess. j and k MRI of the cervical and lumbar spine of patients presenting with an epidural abscess

Critical appraisal of the discussed
classification criteria
Neurologic deficits
A clearrecommendationechoing through
the literature that the presence of pro-
gressive neurologic deficits is a clear
indication for surgical treatment. In
a systematic review of the clinical fea-
tures of PS, the authors observed that
38% of patients suffered from neurologi-
cal dysfunction, such as sensory deficits,
motor weakness or paralysis, radicu-
lopathy and loss of sphincter control.
In almost one quarter of these patients,
paresis or paralysis was reported [10].
Paralysis and severe muscular weak-
ness were associated with certain risk
factors, such as increasing age at diagno-
sis, steroid-induced immunosuppression
and diabetes. Therefore, considering the
presence of neurologic deficits was an
important criterion to utilize in the clas-
sification and treatment guidance of PS
[4, 29], which was used in the three PS
classification systems discussed [11, 21,
22]; however, the classification systems
discussed did not take comorbidities
into consideration.
Abscess formation
A common complication of PS is infec-
tion seeding from neighboring compart-
ments leading to epidural, paravertebral
or psoas abscess formation (. Fig. 1a–k).
In a multicenter study of 7 centers with
253 patients, an epidural abscess in was
found in 17% of cases and a paravertebral
abscess in 26% [12]. Similar to PS, the in-
cidence ofa spinal epidural abscess (SEA),
a debilitating and life-threatening com-
plication, is on the rise. The incidence of
SEA was cited as being between 0.2 and
12.5 cases per 10,000 hospital admissions
[30, 31]. If treatment is delayed, the pa-
tient could be inflicted with irreversible
neurological dysfunction [30, 32].
Many authors consider a SEA with-
out neurologic deficits as an indication
for surgery [15, 21]. In the literature
the decision for conservative versus sur-
gical treatment seems to be contingent
on patient’s neurological status, comor-
bidities, resources and preferences of the
spine surgeon [33]. It is clear that further
studies are warranted to determine who
benefits from whichintervention[33, 34];
however, ethical considerations hamper
randomization efforts for treatment op-
tions of SEA. Some authors even admit
that conducting high-level evidence stud-
ies on this debilitating condition might
be considered utopic [33, 34]. Hence,
retrospective reviews might be the sole
source of information upon which sound
clinical judgement and classification sys-
tems could be built. Similar to PS, an
SEA could be located in the cervical,
thoracic and lumbar spine with its own
unique characteristics; however, the cur-
rent classification systems give general
expert opinion and criteria for surgi-
cal treatment without discriminating be-
tween these unique entities [30]. Cervical
SEA has a lower infection rate than the
thoracic or lumbar spine; however, it has
been associated with a much more debil-
itating functional outcomes and higher
mortality [31]. Thus, some authors con-
sider it a unique entity the management
of which should not be the same as tho-

486 Der Orthopäde 6 · 2020


racic or lumbar SEA [30]. An explanation
could be that the neurological level of in-
jury if one occurs is higher and hence the
resulting spinal cord injury would have
more dramatic consequences. In two of
the largest studies on cervical SEAs, it was
observed that 47–77% of patients with
cervical SEA presented with some form
of a neurological deficit from a paresis of
one extremity to a complete tetraplegia
[30, 35, 36]. Furthermore, in a system-
atic review and meta-analysis on cervical
SEA, the authors noted that the major-
ity of studies on SEA combined cervical,
thoracic, and lumbar abscesses together
hindering conclusions specific to cervi-
cal SEA [30]. It was suggested that ear-
lier surgical intervention could be ben-
eficial in safeguarding neurological out-
come; however, it is an elusive matter
to accurately define this patient popula-
tion. This is because the rate of symptom
progression from back pain to complete
paralysis varies between individuals and
the current literature does not provide a
clear delineation of who profits from early
surgery vs. conservative treatment [30,
37, 38]. Khanna et al. described a faster
neurological deterioration in cervical and
thoracic SEA than lumbar SEA due to the
quicker compression of the spinal cord
and smaller diameter of the spinal canal
[38]. The aforementioned findings un-
derline a need for randomized clinical
studies aimed at comparing the efficacy
of different surgical approaches based on
location of the abscess. The majority of
studies included reported improved out-
comes with immediate surgical interven-
tion and antibiotics [30].
Hadjipavlou et al. analyzed neu-
rological outcomes following spinal
decompression for SEA and observed
a significantly higher rate of paraplegia/
paraparesis prior to surgery and a sig-
nificantly worse outcome postsurgical
outcome in patients with SEA at the
thoracic level compared with the lumbar
spine [34]. Hence, early identification
and a prompt surgical decompression in
the context of progressive neurological
deterioration is a reasonable approach
to mitigate morbidity or mortality in
patient with cervical and thoracic SEA
[34].
Lumbar SEAs are less likely to cause
complications in spondylodiscitis, result
in neurologic deficits or lead to symp-
tomatic neural compression [33]. A sys-
tematic review of lumbar SEA demon-
strated that surgically treated patients
presented more often with worse physical
symptoms and neurologic deficits evident
in their worse ASIA motor level scores.
Interestingly, there seem to be only a few
significant differences in treatment out-
comes between surgically vs. medically
treated patients [33]. Noteworthy, is that
the most important prognostic factor of
good neurological outcome was the ini-
tial status before surgery. The authors
further noted that the current evidence
supporting surgical treatment of lumbar
SEA as the main recommendation lacks
quality due to the deficiency of clinical
trials comparing medical versus surgical
treatment [33].
Fig. 2 9 a Sagittal
schematic representa-
tion of a spine with bone
destruction and epidural
abscess (red) without in-
stability. b and c Sagittal
CT and MRI of patients
presenting with PS without
instability
Spinal segmental instability
Defining segmental instability is a con-
troversial topic [39]. Previous biome-
chanical studies defined instability in the
context of degenerative disease and not
inflammatory disease. Nonetheless, one
could utilize the established methods
to build a consensus and then recali-
brate and reconfigure as the classification
evolves. The concept of stability or in-
stability seems to be a qualitative more
than a quantitative criterion that lacks
evidence-based recommendations and
radiological thresholds [40]. The spine
is a complex biomechanical apparatus
in which three-dimensional kinematics
are exerted [40, 41]. Furthermore, with
its physiological cervical, thoracic and
lumbar curvature the segmental range
of motion (ROM) differs according to
anatomical location. For instance, the
lumbar spine enables increased cephalo-
caudal ROM while the lumbosacral joint
enables more sagittal ROM in flexion-
extension. On the other hand, lateral
bending and axial rotation ROM is almost
equal along the entire spine with the ex-
ception of the lumbosacral joints which
exhibit the least lateral ROM [42]. Hence,
In the context of inflammation it could
be postulated that the location of the in-
fected vertebra determines the pattern of
instability (. Fig. 2a–c). A perturbation
of a spinal segment leads to dysfunc-
tional kinematics of multidirectional
coupled motions of the spinal segment
[40]. To understand segmental stabil-
ity or its opposite, instability, a sound
understanding of spinal kinematics is
Der Orthopäde 6 · 2020 487
 Übersichten
Fig. 3 8 a Sagittal schematic representation of the spine depicting anterolisthesis.b Sagittal CT of the spine illustrating an-
terolisthesis of L3–L4 with bone destruction. c Sagittal schematic representation of the spine depicting retrolisthesis.d Sagit-
tal CT of the spine illustrating anterolisthesis of L2–L3 with bone destruction
necessary [40, 41]. Each spinal motion
segment is comprised of two vertebral
bodies and the connecting ligaments.
Each segment exhibits three types of
kinematics, translation, angulation and
rotation in six degrees of ROM. Hence,
stability or instability should be assessed
accordingly [43]. Current classification
and recommendations take only sagittal
instability into consideration.
Spinal stability is an instrumental req-
uisite for its function in protecting neural
structures [40]. Clinical instability was
defined by White and Panjabi [42] and
Panjabi [44] as the inability of the spine
to safeguard its normal displacement un-
der physiological loads in which there is
no resulting neurologic deficits, incapac-
itating deformity or severe pain. In other
words, the American Academy of Ortho-
pedic Surgeons defined stability as “the
capacity of the vertebrae to remain cohe-
sive and to preserve the normal displace-
ments in all physiological body move-
ments” [45]. There are many proposed
techniques of measurement of instability
in the literature. Albeit the most accepted
threshold was coined by White and Pan-
jabi [42, 44]. White and Panjabi consid-
ered all the thresholds suggested in the
literature and suggested that 4.5 mm of
anterior translation should be the thresh-
old upon which clinicians should con-
sider the lumbar spine to be segmen-
488 Der Orthopäde 6 · 2020
tally unstable. This measurement could
be done in normal resting radiographs.
They also considered 2 mm of posterior
translation to be the threshold of insta-
bility. This threshold was suggested af-
ter they conducted a thorough analysis
of resting radiographs in the acute trau-
matic setting and in the nonacute setting
of the lumbar spine [42, 44]. Further-
more, the authors studied segmental an-
gulation and after analyzing in vivo and
in vitro studies of normal resting sagit-
tal posture of the lumbar spine. sug-
gested that segmental angulation greater
of 22°should be considered unstable. In
the context of degenerative lumbar in-
stability Vaccaro and Ball considered an
angulation of more 10° as unstable [46].
In the context of dynamic radiographs,
authors suggested a segmental axial ro-
tation of more than 15° at L2-L3, L3-L4,
L4-L5 or greater than 25° at L5-S1 [42].
In the setting of cervical instability, John-
son et al. [47] defined instability as when
there is 3.5 mm translation or when there
is more than 11° of rotation difference
of two subjacent vertebrae measured on
lateral X-rays (resting or flexion-exten-
sion). In the context of thoracic insta-
bility, a horizontal translation of 2.5 mm
(on lateral X-ray) or 5° of angulation of
two subjacent vertebrae may be consid-
ered as signs of instability [48]; however,
these were biomechanical studies and an
in vivo analysis was not conducted which
hampers their clinical utility.
Many studies have been conducted to
assess the segmental instability of the tho-
racic and cervical spine; however, these
criteria are not as comprehensive as the
criteria suggested by White and Pan-
jabi and hence there is a certain reluc-
tance to utilize them in future classifica-
tions. Noteworthy, all proposed criteria,
including the ones by White and Pan-
jabi [42], describe instability either in
a physiological, traumatic or degenera-
tive setting. None were described in the
setting of vertebral osteomyelitis. Ak-
bar et al. [21] and Pola et al. [11]
considered a sagittal kyphosis of more
than 25° as a threshold to define seg-
mental instability. It is, however, unclear
why both groups of authors chose this
threshold highlighting the lack of objec-
tivity and lack of quantifications meth-
ods regarding this controversial issue.
Moreover, anterolisthesis and retrolisthe-
sis (. Fig. 3a–d) were not considered [40].
Homagk et al. did not include segmental
instability in their severity score which
could constitute a major limitation of us-
ing their classifying instrument [22, 24].
Finally, in a systematic review by Her-
ren et al. they found the criterion for in-
stability was segmental kyphosis greater
than 15°. Similarly, this statement was
global and does not consider the loca-

tion of this kyphosis [29]. In light of
these discrepancies, it could be suggested
that segmental kyphosis of any degree in
any spinal segment should be regarded
as a criterion for instability (. Fig. 4a–c).
This suggestion arises from the fact that
that the current knowledge about the
topic of spinal instability in general and
especially in the setting of inflammation
is far too immature, which hampers its
clinical and radiological utility [41]. On
the other hand, an avalanche of biome-
chanical and radiological studies is un-
derway to help enlighten the way towards
a more objective and clinically relevant
definition of instability.
Surgical management of PS and its
indications
First-line treatment of PS is usually con-
servative via antibiotics [5]; however, it
has previously been reported that up to
40–50% of patients suffering from PS will
eventually require surgical intervention
[4, 5]. The goals of surgical treatment are
to eradicate the spinal infection, safe-
guard blood perfusion to the infected
tissue, decrease pain and establish seg-
mental stability [15, 29]. There are many
proposed surgical approaches in the lit-
erature. These include anterior and/or
posterior surgery, staged vs. single and
with or without stabilization. The ante-
rior aspect of the vertebrae is most af-
fected by the infection. The posterior
aspect is mostly affected in advanced PS
[5]. Therefore, many surgeons prefer an-
terior debridement in otherwise healthy
patients who might not need posterior
stabilization [5]. To date and to the
best of the authors knowledge, there are
no randomized controlled trial proving
the efficacy of a single surgical approach
over another [4]. Hence, all suggested
approaches by the authors of PS classi-
fications remain subjectively controver-
sial and an evidence-based answer to
the superiority of an approach in a cer-
tain clinical scenario remains unattained.
The timing of surgery is also controver-
sial. Segreto et al. retrospectively ana-
lyzed almost 34,500 patients with PS and
stratified them according to the delay of
surgery. Subsequently, the authors an-
alyzed the postoperative outcomes and
concluded that patients who underwent
surgery within 24 h after admission had
better outcomes than patients with de-
layed surgery who suffered more postop-
erative complications and increased mor-
bidity [5]. The IDSA guidelines stated
that progressive neurologic deficits, im-
minent instability, persistent septicemia,
adamant backpain and formation of an
epidural abscess despite adequate antibi-
otic treatment constitute valid indica-
tions for surgical treatment ([4], . Fig. 5).
Fig. 4 9 a Sagittal
schematic representa-
tion of the spine depicting
inflammation of vertebrae
and intervertebral disc
(red) as well as the result-
ing segmental kyphosis.
b Sagittal CT of the cervical
spine illustrating bone de-
struction with segmental
kyphosis. c Sagittal CT of
the thoracic spine illustrat-
ing bone destruction with
segmental kyphosis
Defining failure of conservative
treatment
There is no consensus between authors on
the exact definition of failure of PS treat-
ment. Unlike many published studies on
PS the IDSA guidelines considered per-
sistent pain, residual neurologic deficits,
elevated markers of systemic inflamma-
tion or radiographic findings alone do
not necessarily signify treatment failure
in treated PS patients [4]. Alternatively,
the IDSA proposed a definition to stan-
dardize reporting of PS treatment out-
comes. Failure of treatment was defined
as a persevering infection with a pos-
itive microbiological detection in spite
of administration of targeted antibiotic
treatment. The authors also noted that
defining failure based solelyonlaboratory
findings, radiographic surrogate markers
and clinical status of the patient with-
out inclusion of microbiological detec-
tion may overestimate treatment failure
and lead to exaggerated medicinal or sur-
gical treatment [4].
Utility of inflammatory markers,
back pain and MRI as indices for
assessing treatment
Inflammatory markers (CRP), pain and
MRI findings represented the main pil-
lars upon which the severity score of
Homagk et al. was designed [22, 24].
Many authors consider adamant fever,
Der Orthopäde 6 · 2020 489
 Übersichten

toms and inflammatory markers. The

IDSA recommends follow-up MRI spe-
cially to monitor paraspinal and epidu-
ral abscesses in patients not respond-
ing to treatment. An explanation could
be that MRI changes frequently perse-
vere or could even be aggravated during
treatment in spite of clinical improve-
ment [15, 56]. Performing a follow-up
MRI sooner than 4 weeks could lead to
a lower threshold of preforming surgery
and an unnecessary lengthy antibiotic
treatment [4, 57]. Interestingly, morpho-
Fig. 5 8 Suggested treatment algorithm for patients presenting with back pain and a clinical pre- logical changes on MRI indicating persis-
sentation suspicious of PS. This algorithm is inspired by the literature review and constitutes the core tentinfectioncould be evidentformonths
treatment plan in this university hospital. N Neurologic deficits, A Abscess formation, S Segmental in-
to years in patients otherwise showing
stability, (0) no, (1) yes. When a patient presents with no neurologic deficits (N0), no abscess formation
on MRI (A0), and no segmental instability (S0), the next best step would be conservative treatment. clinical improvement [4, 57–59]. This
When conservative treatment fails then surgery is indicated.When a patient presents with progressive is another criticism of the MRI criteria
neurologic deficits (N1), epidural abscess (A1) or segmental instability (S1), the best next step would used by Homagk et al. to monitor dis-
be surgery ease progression. Nonetheless, Homagk
et al. address this fact in their score dis-
back pain or continuously elevated in- suspected of having treatment failure. In cussion [24]. On the other hand, total
flammatory markers (CRP higher than summary, an orchestrated assessment of loss of gadolinium enhancement and os-
30 mg/l) as predictors of management clinical status with systemic inflamma- seous healing are revealed late on MRI
failure [49, 50]; however, the advantage of tory markers should be applied to ac- in the course of the healing process [60].
obtaining follow-up inflammatory labo- curately measure efficacy of treatment Moreover, a clear discrepancy between
ratory markers (ESR, CRP) under antibi- [4]. Intuitively, persistent back pain in clinical symptoms and radiological signs
otic treatment for PS has not been con- a patient undergoing treatment for PS has been previously reported. For in-
firmed [4]. The CRP level is elevated in is alarming. In the multicenter study of stance, epidural enhancement and spinal
the majority of cases with spondylodisci- McHenry et al. [12], the most reported canal stenosis were revealed in patients
tis [51]. In a systematic review and meta- finding in patients who failed treatment with improving clinical symptoms [59].
analysis on spondylodiscitis Taylor et al. was persistent backpain. On the other In summary, targeted and suitably timed
showed that CRP was high (>10 mg/l) in hand, many authors including McHenry MRI follow-up should be cautiously con-
85% of patients (1083/1272). Elevated et al. consistently reported that “cured” ducted. A follow-up MRI is indicated
leukocyte counts were observed only in patients with PS complained of persist- especially in cases with an epidural or
43% (457/1052) of patients [6]. More- ing back pain [4, 12, 54, 55]. Therefore, paraspinal abscess to document the mor-
over, Carrage et al. observed that patients interpreting back pain as a main criterion phological response to treatment espe-
who are 60 years or older and immuno- to assess efficacy of treatment might not cially in patients who did not show a clin-
compromized patients had an increased be the best approach. The gold standard ical improvement on administering an-
likelihood to have a normal leukocyte diagnostic modality of PS is MRI of the tibiotic treatment for a suitable duration
count in the setting of an active PS [52]. spine, which has a specificity of 93% and [4]. As a possible solution to the dilemma
This signifies that the leukocyte count a sensitivity of 97% [4]. Increased sig- of assessing treatment failure, the IDSA
seems tobe the leasthelpful inflammatory nal intensity on T2-weighted images, de- proposed image-guided biopsy for ob-
marker. It has already been shown that creased signal intensity on T1-weighted taining histological samples and micro-
CRP correlates with the clinical symp- images and loss of delineation of verte- biological testing [4]. Facing a patient
tomatology of patients with PS [4, 50]. bral endplates are distinctive features of with suspected treatment failure repre-
Notwithstanding, it has been reported PS-induced changes of the vertebral body sents a true challenge. An individual-
that the majority of patients with persis- and neighboring discs [4, 15]. The sys- ized case by case approach incorporat-
tently increased inflammatory markers tematic review of Taylor et al. [6] revealed ing all the aforementioned factors and an
in a 4–8 week follow-up had a favor- that MRI scans accurately detected PS in interdisciplinary multidimensional pro-
able clinical outcome [4, 53]. The IDSA 94% (980/1045). Homagk et al. consid- cess comprising spine surgeons, neuro-
guidelines recommended that inflamma- ered MRI changes to be essential in their surgeons, radiologists and infectious dis-
tory markers should be reassessed after score to diagnose and monitor treatment eases specialists is warranted to tackle this
4 weeks of antibiotic treatment. Patients [22, 24]; however, IDSA guidelines [4] complex problem [4].
with unchanged or worsening inflamma- advised against follow-up MRI in patients
tory markers after 4 weeks should be who exhibited improved clinical symp-

490 Der Orthopäde 6 · 2020


Conclusion
A PS remains a real challenge despite
the recent advances in early diagnosis
and treatment strategies. The goals of
treatment are to eradicate the infection,
safeguard neurological function and halt
the progress of deformity. In the con-
text of interdisciplinary management of
PS, a clinically utile orthopedic classi-
fication should be kept clinically and
radiologically as simple as possible to
suit spine professionals and surgeons of
all training expertise. Thus far, there
is neither a uniform orthopedic classi-
fication system nor a treatment algo-
rithm to guide its management. This
controversy could be the culprit behind
overtreatment or undertreatment result-
ing in increased postoperative complica-
tions and increased costs burden to the
health economic system [5]. Published
classification systems encompass clini-
cal and radiological criteria to classify
and guide the management of PS. The
presence or lack of neurologic deficits,
abscess formation and segmental insta-
bility, increased inflammatory markers
and MRI morphological changes repre-
sent the main pillars of these classification
systems. The aim of these classifications
is to establish a process-based and multi-
dimensional rethinking of PS; however,
these systems do not take all the clinically
relevant factors into account and some
definitions used could not be considered
evidence based. For instance, evidence-
based thresholds of defining segmental
instability should be utilized in a future
classification taking specific spinal kine-
matics dictated by the anatomic location
of the inflamed segments into considera-
tion. The current discrepancies pertain-
ing to instability could motivate clinicians
to consider segmental kyphosis of any de-
gree in any spinal segment as a sign of
instability. Moreover, they only consider
angular instability and do not take ante-
rior or posterior translation as criteria for
instability into consideration. Unfortu-
nately, current classification systems are
only retrospectively validated in single
center retrospective studies and hence are
laden with biases signifying their lack of
mature evolution which invites lack of
consensus. These classifications need to
be validated in a multicenter study in
which multiple cases of PS are presented
to orthopedic surgeons of all career stages
and tested for feasibility, validity, inter-
rater and intrarater reliability. Despite the
fact that PS of the cervical spine is asso-
ciated with worse neurological outcome,
the discussed classification systems do
not take this point into consideration.
Spinal epidural abscesses could be lo-
cated in the cervical, thoracic and lumbar
spine, each with its own unique charac-
teristics; however, the current classifica-
tion systems give general expert opinion
and criteria for surgical treatment ubiq-
uitously without discriminating between
these unique entities. Lastly, none of
the classifications considered concomi-
tant patient comorbidities which could
downplay their clinical utility.
In summary, an orchestrated assess-
ment of clinical signs, serological results,
radiographic changes on MRI and a well-
defined approach to defining stability or
imminent segmental instability should be
applied. In light of the current literature
and published guidelines, depending on
surrogate markers alone could falsely sig-
nify a persistent infection without a clin-
ical correlation. Hence, this approach
could lead to overtreatment with unnec-
essary surgery or lengthy antibiotic treat-
ment. Hitherto, there is a lot of room for
evolution and improvement for current
classification systems of PS to reach in-
ternational consensus.
Corresponding address
M. Akbar, MD
Department of Orthopaedic
Surgery, Trauma Surgery and
Spinal Cord Injury, Heidelberg
University
Schlierbacher Landstraße
200A, 69118 Heidelberg,
Germany
michael.akbar@
med.uni-heidelberg.de
Compliance with ethical
guidelines
Conflict of interest H. Almansour, W. Pepke and
M. Akbar declare that they have no competing inter-
ests.
For this article no studies with human participants
or animals were performed by any of the authors. All
studies performed were in accordance with the ethical
standards indicated in each case.
References
1. Zimmerli W (2010) Vertebral osteomyelitis. N Engl
J Med 362(11):1022–1029
2. Pola E et al (2018) Multidisciplinary management
of pyogenic spondylodiscitis: epidemiological
and clinical features, prognostic factors and long-
term outcomes in 207 patients. Eur Spine J
27(2):229–236
3. Lu M-L et al (2015) Transforaminal lumbar
interbody debridement and fusion for the
treatment of infective spondylodiscitis in the
lumbar spine. Eur Spine J 24(3):555–560
4. Berbari EF et al (2015) 2015 Infectious Diseases
Society of America (IDSA) clinical practice
guidelines for the diagnosis and treatment of
native vertebral osteomyelitis in adults. Clin Infect
Dis 61(6):e26–e46
5. Segreto FA et al (2018) Vertebral osteomyelitis:
a comparison of associated outcomes in early
versus delayed surgical treatment. Int J Spine Surg
12(6):703–712
6. Taylor DG et al (2018) Presentation and outcomes
after medical and surgical treatment versus med-
ical treatment alone of spontaneous infectious
spondylodiscitis: asystematicliteraturereviewand
meta-analysis. Global Spine J 8(4_suppl):49S–58S
7. Stoeckle M et al (2008) The role of diabetes mellitus
inpatientswithbloodstreaminfections. SwissMed
Wkly 138(35):512
8. SobottkeRetal(2009)Treatmentofspondylodisci-
tis in human immunodeficiency virus-infected
patients: a comparison of conservative and
operative therapy. Spine 34(13):E452–E458
9. Grammatico L et al (2008) Epidemiology of
vertebral osteomyelitis (VO) in France: analysis of
hospital-discharge data 2002–2003. Epidemiol
Infect 136(5):653–660
10. Mylona E et al (2009) Pyogenic vertebral os-
teomyelitis: a systematic review of clinical charac-
teristics. Semin Arthritis Rheum 39(1):10–17
11. Pola E et al (2017) New classification for the
treatment of pyogenic spondylodiscitis: validation
studyonapopulationof250 patientswithafollow-
up of 2 years. Eur Spine J 26(4):479–488
12. McHenryMC, EasleyKA, LockerGA(2002)Vertebral
osteomyelitis: long-term outcome for 253 patients
from 7 Cleveland-area hospitals. Clin Infect Dis
34(10):1342–1350
13. Bucher E et al (2000) Spondylodiscitis associated
with bacteraemia due to coagulase-negative
staphylococci. Eur J Clin Microbiol Infect Dis
19(2):118–120
14. Bernard L et al (2015) Antibiotic treatment for
6 weeks versus 12 weeks in patients with pyogenic
vertebral osteomyelitis: an open-label, non-
inferiority, randomised, controlled trial. Lancet
385(9971):875–882
15. Gouliouris T, Aliyu SH, Brown NM (2010) Spondy-
lodiscitis: update on diagnosis and management.
J Antimicrob Chemother 65(suppl_3):iii11–iii24
16. Sendi P, Bregenzer T, Zimmerli W (2008) Spinal
epidural abscess in clinical practice. QJM
101(1):1–12
17. Wirtz DC et al (2000) Diagnostic and therapeutic
management of lumbar and thoracic spondy-
Der Orthopäde 6 · 2020 491

lodiscitis—an evaluation of 59 cases. Arch Orthop
Trauma Surg 120(5-6):245–251
18. Eismont FJ et al (1983) Pyogenic and fungal
vertebral osteomyelitis with paralysis. J Bone Joint
Surg Am 65(1):19–29
19. BatemanJL,PevznerMM(1995)SpinalOsteomyeli-
tis: a review of 10 years’experience. Orthopedics
18(6):561–565
20. Jensen AG et al (1998) Bacteremic staphylo-
coccus aureus spondylitis. Arch Intern Med
158(5):509–517
21. Akbar M et al (2011) Pyogenic spondylodiscitis
of the thoracic and lumbar spine: a new
classification and guide for surgical decision-
making. Orthopäde 40(7):614–623
22. Homagk L et al (2016) Spondylodiscitis severity
code: scoring system for the classification and
treatment of non-specific spondylodiscitis. Eur
Spine J 25(4):1012–1020
23. Akbar M et al (2012) Pyogene Spondylodiszitis:
Therapiealgorithmus und neue Klassifikation
zur therapeutischen Entscheidungsfindung (Leit-
thema). Orthopäde 41(9):749–758
24. Homagk L et al (2019) SponDT (spondylodiscitis
diagnosisandtreatment): spondylodiscitisscoring
system. J Orthop Surg Res 14(1):100
25. Chapman JR, Dettori JR, Norvell DC (2009) Spine
classifications and severity measures. Thieme,
Stuttgart
26. Mirza SK et al (2002) Classifications of thoracic and
lumbar fractures: rationale and supporting data.
J Am Acad Orthop Surg 10(5):364–377
27. Field MJ, Lohr KN (1990) Clinical practice guide-
lines: directions for a new program. National
Academies Press, Washington
28. Audigé L, Bhandari M, Kellam J (2004) How reliable
are reliability studies of fracture classifications? A
systematic review of their methodologies. Acta
Orthop Scand 75(2):184–194
29. Herren C et al (2017) Spondylodiscitis: diagnosis
and treatment options: a systematic review. Dtsch
Ärztebl Int 114(875):51–52
30. Stricsek G et al (2018) Etiology and surgical
management of cervical spinal epidural abscess
(SEA): a systematic review. Global Spine J
8(4_suppl):59S–67S
31. Rigamonti D et al (1999) Spinal epidural abscess:
contemporary trends in etiology, evaluation, and
management. Surg Neurol 52(2):189–197
32. Howie BA et al (2018) Thoracic epidural ab-
scesses: a systematic review. Global Spine J
8(4_suppl):68S–84S
33. de Leeuw CN et al (2018) Lumbar epidural
abscesses: a systematic review. Global Spine J
8(4_suppl):85S–95S
34. Hadjipavlou AG et al (2000) Hematogenous
pyogenic spinal infections and their surgical
management. Spine 25(13):1668–1679
35. Ghobrial GM et al (2015) Surgical management
in 40 consecutive patients with cervical spinal
epidural abscesses. Spine 40(17):E949–E953
36. Alton TB et al (2015) Is there a difference in
neurologic outcome in medical versus early
operative management of cervical epidural
abscesses? Spine J 15(1):10–17
37. Tuchman A, Pham M, Hsieh PC (2014) The
indications and timing for operative management
of spinal epidural abscess: literature review and
treatment algorithm. Neurosurg Focus 37(2):E8
38. Khanna RK et al (1996) Spinal epidural abscess:
evaluation of factors influencing outcome.
Neurosurgery 39(5):958–964
39. Szpalski M (1996) The mysteries of segmental
instability. Bull NYU Hosp Jt Dis 55(3):147
492 Der Orthopäde 6 · 2020
40. Izzo R et al (2013) Biomechanics of the spine. Part I:
spinal stability. Eur J Radiol 82(1):118–126
41. Izzo R et al (2013) Biomechanics of the spine. Part II:
spinal instability. Eur J Radiol 82(1):127–138
42. White A, Panjabi MM (1990) Clinical biomechanics
of the spine, 2nd edn. Lippincott Williams &
Wilkins, Philadelphia
43. Gopinath P (2015) Lumbar segmental instability:
points to ponder. J Orthop 12(4):165
44. Panjabi MM (1992) The stabilizing system of
the spine. Part II. Neutral zone and instability
hypothesis. J Spinal Disord 5:390–390
45. Kirkaldy-Willis W (1985) Presidential symposium
on instability of the lumbar spine: introduction.
Spine 10(3):254
46. Vaccaro AR, Ball ST (2000) Indications for in-
strumentation in degenerative lumbar spinal
disorders. Orthopedics 23(3):260–271
47. Johnson R, Panjabi M, Southwick W (1975)
Biomechanical analysis of clinical stability in the
cervical spine. Clin Orthop Relat Res 109:85–96
48. Panjabi MM, Hausfeld JN, White AA (1981) A
biomechanical study of the ligamentous stability
of the thoracic spine in man. Acta Orthop Scand
52(3):315–326
49. Kowalski TJ et al (2006) Do follow-up imaging ex-
aminations provide useful prognostic information
in patients with spine infection? Clin Infect Dis
43(2):172–179
50. Khan MH et al (2006) Serum C-reactive protein
levels correlate with clinical response in patients
treated with antibiotics for wound infections after
spinal surgery. Spine J 6(3):311–315
51. Chelsom J, Solberg CO (1998) Vertebral os-
teomyelitis at a Norwegian university hospital
1987–97: clinical features, laboratory findings and
outcome. Scand J Infect Dis 30(2):147–151
52. Carragee EJ (1997) Pyogenic vertebral osteomyeli-
tis. J Bone Joint Surg Am 79(6):874–880
53. Carragee EJ et al (1997) The clinical use of
erythrocyte sedimentation rate in pyogenic
vertebral osteomyelitis. Spine 22(18):2089–2093
54. del Pozo JSG, Soto MV, Solera J (2007) Vertebral
osteomyelitis: long-term disability assessment
and prognostic factors. J Infect 54(2):129–134
55. O’Daly BJ, Morris SF, O’Rourke SK (2008) Long-term
functional outcome in pyogenic spinal infection.
Spine 33(8):E246–E253
56. Euba G et al (2008) Long-term clinical and radi-
ological magnetic resonance imaging outcome
of abscess-associated spontaneous pyogenic
vertebral osteomyelitis under conservative man-
agement. Semin Arthritis Rheum 38(1):28–40
57. Carragee EJ (1997) The clinical use of mag-
netic resonance imaging in pyogenic vertebral
osteomyelitis. Spine 22(7):780–785
58. Wang Q et al (2010) Utility of MRI in the follow-up
of pyogenic spinal infection in children. Pediatr
Radiol 40(1):118
59. Kowalski T et al (2007) Follow-up MR imaging
in patients with pyogenic spine infections: lack
of correlation with clinical features. AJNR Am J
Neuroradiol 28(4):693–699
60. Gillams A, Chaddha B, Carter A (1996) MR
appearances of the temporal evolution and
resolution of infectious spondylitis. AJR Am J
Roentgenol 166(4):903–907
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RheumaPreis 2020
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rheumatischer Erkrankung
„Gemeinsam AufRheumen am Ar-
beitsplatz“ – unter diesem Motto ruft
die Initiative RheumaPreis in diesem
Jahr zum zwölften Mal dazu auf, sich
für die gleichnamige Auszeichnung
zu bewerben. Denn „aufzurheumen“
gibt es noch immer vieles, wenn es
darum geht, trotz einer entzündlich-
rheumatischen Erkrankung weiter
berufstätig zu sein.
Die Initiative RheumaPreis in diesem Jahr
zum zwölften Mal dazu auf, sich für die
gleichnamige Auszeichnung zu bewer-
ben. Die Initiative „RheumaPreis“ sucht
auch in diesem Jahr wieder Menschen
mit Rheuma, denen es gemeinsam mit
ihren Arbeitgebern gelungen ist, ihr Ar-
beitsumfeld umzugestalten und so ihren
Arbeitsplatz und die Freude am Beruf zu
erhalten. Die Bewerbung für den Rheuma-
Preis steht jedem offen, der an Rheuma
erkrankt ist und einer Berufstätigkeit nach-
geht. Teams können sich ebenso melden
wie Einzelpersonen, Selbstständige ebenso
wie Auszubildende oder Angestellte. Der
Preis wird von einer unabhängigen Jury an
den Arbeitnehmer und seinen Arbeitgeber
vergeben. Das Preisgeld von 3000 Euro
erhält der Arbeitnehmer.
Bewerbungsschluss
ist der 30. Juni 2020.
Die Bewerbung kann per Post
oder online eingereicht werden.
Bewerbungsunterlagen online:
https://rheumapreis.de/bewerbung/
bewerbungsinformationen/
Informationen zu den Mitgliedern
und Initiatoren der Initiative
„RheumaPreis“ finden Sie unter:
http://rheumapreis.de/partner/
S. Priester,
Pressestelle RheumaPreis
www.rheumapreis.de
Hier steht eine Anzeige.