Die konservative und operative Therapie der unspezifischen Spondylodiszitis

Zusammenfassung

Die pyogene Spondylodiszitis entsteht meist endogen durch eine Bakteriämie, aber auch exogene Ursachen wie etwa wirbelsäulennahe Infiltrationen können sie hervorrufen. Es besteht eine zunehmende Inzidenz der Erkrankung, die noch immer mit einer signifikanten Mortalität der in vielen Fällen immunsupprimierten und hochbetagten Patienten einhergeht. Eine frühzeitige Diagnosestellung durch Bildgebung und Erregerisolierung ist entscheidend für ein gutes Behandlungsergebnis. Die überwiegende Zahl der Patienten kann konservativ behandelt werden, wichtig sind ein frühzeitiger Beginn der antibiotischen Therapie sowie eine adäquate Ruhigstellung. Operative Therapieziele sind neben der Dekompression und Infektsanierung die Stabilisation und Deformitätenkorrektur. Es kommen rein dorsale offene Verfahren, ggf. mit Ausräumung der Bandscheibe und TLIF, sowie minimalinvasive Stabilisierungen zur Anwendung. Bei ausgeprägten ventralen Destruktionen, Fehlstellungen und Abszedierungen muss durch einen separaten ventralen Zugang debridiert und stabilisiert werden. In der überwiegenden Zahl der Fälle können gute Behandlungsergebnisse erreicht werden, in Einzelfällen bestehen jedoch große therapeutische Herausforderungen. Individuelle Therapieentscheidungen sind notwendig, da einerseits die Literatur keine eindeutigen Behandlungsleitlinien vorgibt und es sich andererseits um teils hochbetagte und multimorbide Patienten handelt.

Abstract

Bacterial spondylodiscitis is mostly caused by endogeneous bacteremia, but also by direct external inoculation like perispinal infiltrations. There is an increasing incidence of this disease, which is still associated with a high mortality rate especially in the group of advanced aged or immunosuppressed patients. An early diagnosis by imaging and microbiology is essential for a good clinical outcome. The majority of patients can be treated conservatively, early antibiotic treatment and adequate immobilisation are important. Besides decompression and debridement, the goals of surgical therapy are stabilisation and deformity correction. Single standard posterior approaches, eventually with disc resection and TLIF/PLIF, as well as minimal invasive percutaneous stabilisation are being performed. In cases of severe anterior defects, deformities or abscesses, a separate anterior approach needs to be performed for debridement and stabilisation. In the majority of cases, a good outcome can be achieved, nevertheless single cases can be a therapeutic challenge. Individual therapeutical decisions are necessary since on the one hand the literature does not give explicit guidelines, and on the other hand high aged and multimorbid patients are being treated.

Schlüsselwörter

Spondylodiszitis - Antibiotika - konservative Therapie - operative Therapie

Keywords

spondylodiscitis - antibiotics - conservative therapy - surgical therapy

• Literatur

• 1 Akiyama T, Chikuda H, Yasunaga H. et al. Incidence and risk factors for mortality of vertebral osteomyelitis: a retrospective analysis using the Japanese diagnosis procedure combination database. BMJ Open 2013; 3: e002412
• 2 Kehrer M, Pedersen C, Jensen TG. et al. Increasing incidence of pyogenic spondylodiscitis: a 14-year population-based study. J Infect 2014; 68: 313-320
• 3 Pola E, Autore G, Formica VM. et al. New classification for the treatment of pyogenic spondylodiscitis: validation study on a population of 250 patients with a follow-up of 2 years. Eur Spine J 2017;
• 4 Ascione T, Balato G, Di Donato SL. et al. Clinical and microbiological outcomes in haematogenous spondylodiscitis treated conservatively. Eur Spine J 2017;
• 5 Yeom JA, Lee IS, Suh HB. et al. Magnetic Resonance Imaging Findings of Early Spondylodiscitis: Interpretive Challenges and Atypical Findings. Korean J Radiol 2016; 17: 565-580
• 6 Valancius K, Hansen ES, Hoy K. et al. Failure modes in conservative and surgical management of infectious spondylodiscitis. Eur Spine J 2013; 22: 1837-1844
• 7 Tsai TT, Yang SC, Niu CC. et al. Early surgery with antibiotics treatment had better clinical outcomes than antibiotics treatment alone in patients with pyogenic spondylodiscitis: a retrospective cohort study. BMC Musculoskelet Disord 2017; 18: 175
• 8 Quack V, Hermann I, Rath B. et al. [Current treatment strategies for spondylodiscitis in surgical clinics in Germany]. Z Orthop Unfall 2014; 152: 577-583
• 9 Rutges JP, Kempen DH, van Dijk M. et al. Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review. Eur Spine J 2016; 25: 983-999
• 10 Karadimas EJ, Bunger C, Lindblad BE. et al. Spondylodiscitis. A retrospective study of 163 patients. Acta Orthop 2008; 79: 650-659
• 11 Nasto LA, Colangelo D, Mazzotta V. et al. Is posterior percutaneous screw-rod instrumentation a safe and effective alternative approach to TLSO rigid bracing for single-level pyogenic spondylodiscitis? Results of a retrospective cohort analysis. Spine J 2014; 14: 1139-1146
• 12 Weckbach S, Lutz B, Wolfle-Roos JV. et al. [Infections of the spine : Therapeutic strategies]. Chirurg 2016; 87: 839-846
• 13 Michiels I, Jäger M. Spondylodiszitis. Aktuelle Strategien zur Diagnose und Therapie. Orthopäde 2017; 6
• 14 Duarte RM, Vaccaro AR. Spinal infection: state of the art and management algorithm. Eur Spine J 2013; 22: 2787-2799
• 15 Zarghooni K, Rollinghoff M, Sobottke R. et al. Treatment of spondylodiscitis. Int Orthop 2012; 36: 405-411
• 16 Gasbarrini A, Boriani L, Nanni C. et al. Spinal infection multidisciplinary management project (SIMP): from diagnosis to treatment guideline. Int J Immunopathol Pharmacol 2011; 24: 95-100
• 17 Babouee FluryB, Elzi L, Kolbe M. et al. Is switching to an oral antibiotic regimen safe after 2 weeks of intravenous treatment for primary bacterial vertebral osteomyelitis?. BMC Infect Dis 2014; 14: 226
• 18 Bernard L, Dinh A, Ghout I. et al. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet 2015; 385: 875-882
• 19 Patel AR, Alton TB, Bransford RJ. et al. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J 2014; 14: 326-330
• 20 Yoshimoto M, Takebayashi T, Kawaguchi S. et al. Pyogenic spondylitis in the elderly: a report from Japan with the most aging society. Eur Spine J 2011; 20: 649-654
• 21 Lerner T, Hackenberg L, Rosler S. et al. [Surgical therapy of unspecific and specific Spondylodiscitis]. Z Orthop Ihre Grenzgeb 2005; 143: 204-212
• 22 Kinoshita M, Takao S, Takechi K. et al. Percutaneous drainage of psoas and iliopsoas muscle abscesses with a one-step technique under real-time computed tomography fluoroscopic guidance. J Med Invest 2016; 63: 323-327
• 23 Rayes M, Colen CB, Bahgat DA. et al. Safety of instrumentation in patients with spinal infection. J Neurosurg Spine 2010; 12: 647-659
• 24 Liljenqvist U, Lerner T, Bullmann V. et al. Titanium cages in the surgical treatment of severe vertebral osteomyelitis. Eur Spine J 2003; 12: 606-612
• 25 Korovessis P, Vardakastanis K, Fennema P. et al. Mesh cage for treatment of hematogenous spondylitis and spondylodiskitis. How safe and successful is its use in acute and chronic complicated cases? A systematic review of literature over a decade. Eur J Orthop Surg Traumatol 2016; 26: 753-761
• 26 Shousha M, Heyde C, Boehm H. Cervical spondylodiscitis: change in clinical picture and operative management during the last two decades. A series of 50 patients and review of literature . Eur Spine J 2015; 24: 571-576
• 27 Si M, Yang ZP, Li ZF. et al. Anterior versus posterior fixation for the treatment of lumbar pyogenic vertebral osteomyelitis. Orthopedics 2013; 36: 831-836
• 28 Shetty AP, Aiyer SN, Kanna RM. et al. Pyogenic lumbar spondylodiscitis treated with transforaminal lumbar interbody fusion: safety and outcomes. Int Orthop 2016; 40: 1163-1170
• 29 Tschoke SK, Fuchs H, Schmidt O. et al. Single-stage debridement and spinal fusion using PEEK cages through a posterior approach for eradication of lumbar pyogenic spondylodiscitis: a safe treatment strategy for a detrimental condition. Patient Saf Surg 2015; 9: 35
• 30 Madert J, Liem M, Frosch KH. et al. [Dorsolateral access and interbody spinal fusion in spondylodiscitis of the thoracolumbar spine (TLIF technique)]. Oper Orthop Traumatol 2013; 25: 262-272
• 31 Schomacher M, Finger T, Koeppen D. et al. Application of titanium and polyetheretherketone cages in the treatment of pyogenic spondylodiscitis. Clin Neurol Neurosurg 2014; 127: 65-70
• 32 Robinson Y, Tschoeke SK, Kayser R. et al. Reconstruction of large defects in vertebral osteomyelitis with expandable titanium cages. Int Orthop 2009; 33: 745-749