Eur Spine J (2017) 26 (Suppl 4):S479–S488

DOI 10.1007/s00586-017-5043-5

ORIGINAL ARTICLE

New classification for the treatment of pyogenic spondylodiscitis:

validation study on a population of 250 patients with a follow-up
of 2 years
Enrico Pola1 • G. Autore1 • V. M. Formica2 • V. Pambianco1 • D. Colangelo1 •

R. Cauda3 • M. Fantoni3

Received: 12 February 2017 / Revised: 7 March 2017 / Accepted: 11 March 2017 / Published online: 21 March 2017
 Springer-Verlag Berlin Heidelberg 2017

Abstract was 92.80%. 140 patients (56.00%) were treated conser-

Purpose Pyogenic spondylodiscitis (PS) is still burdened vatively with average time of immobilization of
by a high rate of orthopedic and neurological complica- 218.17 ± 9.89 days. Both VAS and SF-12 scores
tions. Despite the rising incidence, the choice of a proper improved across time points in all classes. Residual chronic
orthopedic treatment is often delayed by the lack of clinical back pain occurred in 27 patients (10.80%). Overall
data. The aim of this study was to propose a clinical-ra- observed mortality was 4.80%.
diological classification of pyogenic spondylodiscitis to Conclusions Standardized treatment of PS is highly rec-
define a standard treatment algorithm. ommended to ensure patients a good quality of life. The
Methods Based on data from 250 patients treated from proposed scheme includes all available orthopedic treat-
2008 to 2015, a clinical-radiological classification of pyo- ments and helps spine surgeons to significantly reduce
genic spondylodiscitis was developed. According to pri- complications and costs and to avoid overtreatment.
mary classification criteria (bone destruction or segmental
instability, epidural abscesses and neurological impair- Keywords Spondylodiscitis
Classification

ment), three main classes were identified. Subclasses were Healing rate
Complications
defined according to secondary criteria. PS without seg-
mental instability or neurological impairment was treated
conservatively. When significant bone loss or neurological Introduction
impairment occurred, surgical stabilization and/or decom-
pression were performed. All patients underwent clinical Pyogenic spondylodiscitis (PS) is a potentially life-threat-
and radiological 2-year follow-up. ening infectious disease involving the intervertebral disc
Results Type A PS occurred in 84 patients, while 46 cases and adjacent vertebral bodies. Previous studies estimated
were classified as type B and 120 as type C. Average time the annual incidence of pyogenic spondylodiscitis ranging
of hospitalization was 51.94 days and overall healing rate from 0.4 to 2.4/100,000 inhabitants in Europe [1, 2]. The
variability of available data about incidence depends on the
inclusion criteria and statistical methods of the few existing
& Enrico Pola studies covering limited geographical areas. PS occurs
[email protected] predominantly in elderly and chronically debilitated
1
patients aged over 50 years and is more common in male
Division of Spine Surgery, Department of Orthopaedics and
Traumatology, ‘‘A. Gemelli’’ University Hospital, Catholic
patients, with a male to female ratio of 1.5–2:1 [1, 3, 4].
University of Rome, 00168 Rome, Italy Pyogenic spondylodiscitis has always been considered a
2 rare condition in Europe according to the few epidemio-
Department of Orthopaedics and Traumatology, ‘‘Umberto I’’
University Hospital, La Sapienza University of Rome, logical reports available in the past. However, several
00185 Rome, Italy recent studies reported an alarming increase of incidence in
3
Department of Infectious Diseases, ‘‘A. Gemelli’’ University Europe in the last 20 years. A Danish 14-year population-
Hospital, Catholic University of Rome, 00168 Rome, Italy based study showed that overall incidence of PS increased

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2.2–5.8 cases per 100,000 person years [5]. Aging popu- radiological features to define a simple and reproducible
lation and longer life expectancy of patients affected by treatment algorithm for spine surgeons.
chronic debilitating diseases and immunodeficiency led to
an increased number of high-risk individuals, while the
spread of invasive and minimally invasive diagnostic and Materials and methods
surgical procedures exposed more patients to iatrogenic
infections. The increase of incidence is also due to the Based on data from 250 patients treated at our University
higher diagnostic efficacy obtained with the spread of MRI. Hospital from 2008 to 2015 with a 2-year follow-up, a
Estimated mortality is highly variable depending on geo- clinical-radiological classification of pyogenic spondy-
graphical areas with reported peaks up to 11% [6–10]. lodiscitis was developed. Both spine surgeons and infec-
tious diseases specialists were involved in caring of all the
Etiology and infection routes patients establishing a multidisciplinary clinical manage-
ment. Diagnostic approach included accurate anamnesis
According to etiology, pyogenic or non-specific spondy- and physical examination, serial C-reactive protein (CRP),
lodiscitis can be differentiated into bacterial, fungal or erythrocyte sedimentation rate (ESR), complete blood
parasitic infections. Among bacterial PS, Staphylococcus count, and full spine contrast-enhanced MRI (or CT when
aureus is the most frequent causative microorganism contraindicated). Blood cultures were collected from all
accounting for half of the cases, while fungal and parasitic patients after adequate antibiotics interruption and just
forms represent less than 2% of all cases [6]. PS is in most before and after every invasive procedure. Patients with
cases a hematogenous infection due to septic dissemination negative blood cultures underwent CT-guided biopsy,
from distant infectious foci. The development of PS by while surgical transpedicular biopsy was used as third line
direct inoculation is less common than hematogenous isolation technique [13].
spread and can occur following spinal surgery, epidural All patients received intravenous antibiotic therapy for
procedures and lumbar puncture with a reported prevalence at least 4 weeks followed by oral course until normaliza-
up to 18.8% [11]. Through the osteonecrosis, the infection tion of radiological and laboratory markers of infection
can spread to paravertebral soft tissues and epidural space [17]. Patients without etiological diagnosis even after sur-
producing abscesses and leading to biomechanical insta- gical biopsy, received empiric broad-spectrum antibiotic
bility and neurological impairment in about 1/3 of all cases therapy and underwent closer blood tests monitoring [17].
[3, 6, 7]. Conservative orthopedic treatment consisted of 24/7
immobilization with rigid orthosis until complete infection
Treatment goals healing. Rigid orthosis consisted on hard cervical collar
with proper chin support, or thoraco-lumbar rigid brace
Treatment of pyogenic spondylodiscitis is a story of great molded on plaster cast to avoid kyphosis. Posterior per-
successes which led from the mortality rate of about 70% cutaneous screw-rod instrumentation bridging the infected
observed by Kulowski in 1936 to nowadays optimal clin- level was used as alternative minimally invasive approach
ical outcomes [12]. First aim of the treatment strategy to orthosis in patients with single-level thoraco-lumbar PS
should be to eradicate the infection and prevent sepsis. and high functional demand. Open surgical treatment
However, while the antibiotic therapy greatly reduced included debridement of necrotic tissues, decompression of
mortality, PS is still burdened by a high rate of orthopedic neurological structures and spine instrumentation, avoiding
and neurological complications with great impact on infected vertebral bodies, through anterior or posterior
patients’ quality of life [9, 10]. The goals of orthopedic approaches. The same orthopedic treatments were used in
treatment are to preserve or establish spinal stability, to patients without microbiological diagnosis.
relieve pain, to prevent or reverse neurological deficits and Physical examination, serial blood tests and targeted
to prevent recurrence [13–16]. MRI were performed at 1, 3, 6, 12 and 24 months from
Practical guidelines for the pharmacological manage- diagnosis. At each follow-up visit, patients were also asked
ment of PS have been proposed by the Infectious Diseases to fill in Visual Analogic Scale (VAS) and Short-Form 12
Society of America (IDSA) in 2015 [17]. On the other (SF-12) questionnaires.
hand, the lack of large clinical studies and the variability of
inclusion criteria of existing clinical series still hinder the Classification criteria
development of a standard algorithm for orthopedic
treatment. Classification criteria were selected among clinical and
Aim of this study is to propose a new classification of radiological factors with known prognostic value. Three
pyogenic spondylodiscitis based on clinical and main types (A, B and C) were defined depending on to the

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following primary criteria: bone destruction or segmental Type B

instability, epidural abscesses and neurological impairment
(Table 1). Secondary criteria were: involvement of par- All cases with radiological evidence of significant bone
avertebral soft tissues and intramuscular abscesses destruction or biomechanical instability without acute
(Table 1). Biomechanical instability was defined as more neurological impairment or epidural abscesses were
than 25% change of segmental kyphosis at the infection included (Fig. 2). Patients were treated according to the
level. Accurate physical examination including evaluation following subclasses:
of deep tendon reflexes, sensibility, muscle strength and
• B.1: destructive spondylodiscitis without segmental
central pathological signs, was performed to exclude neu-
instability (Fig. 2a).
rological impairment. Contrast-enhanced MRI was used to
• B.2: destructive spondylodiscitis extended to paraver-
evaluate neurological structures, abscesses and involve-
tebral soft tissues without segmental instability
ment of paravertebral soft tissues.
(Fig. 2b).
• B.3: destructive spondylodiscitis with biomechanical
Type A
instability and segmental kyphosis (B.3.1 \ 25;
B.3.2 [ 25) (Fig. 2c).
All cases without biomechanical instability neither acute
neurological impairment or epidural abscesses were Conservative treatment or percutaneous stabilization
included (Fig. 1). Depending on secondary criteria, sub- was indicated for destructive PS with preserved spine sta-
classes were defined as follow: bility (B.1 and B.2) (Table 2). When segmental kyphosis or
instability occurred (B.3), surgical stabilization was always
• A.1: simple discitis without the involvement of verte-
performed (Table 2). Minimally invasive posterior percu-
bral bodies (Fig. 1a).
taneous approach was considered an option to treat patients
• A.2: spondylodiscitis involving the intervertebral disc
with mild kyphosis (B.3.1).
and adjacent vertebral bodies (Fig. 1b).
• A.3: spondylodiscitis with limited involvement of
Type C
paravertebral soft tissues (Fig. 1c).
• A.4: spondylodiscitis with unilateral (A.4.1) or bilateral
All cases with epidural abscesses or acute neurological
(A.4.2) intramuscular abscesses (Fig. 1d).
impairment were included (Fig. 3).
Treatment of choice was 24/7 rigid orthosis immobi-
• C.1: epidural abscess without neurological symptoms
lization until complete infection healing (Table 2). Patients
neither segmental instability (Fig. 3a).
with higher functional demand underwent minimally
• C.2: epidural abscess and segmental instability without
invasive posterior percutaneous stabilization (Table 2).
neurological impairment (Fig. 3b).

Table 1 Classification scheme according to primary and secondary criteria

Classes Bone destruction Segmental instability Epidural abscess Neurological impairment Paravertebral involvement

Type A No No No No Yes/no
A.1 No No No No No (simple discitis)
A.2 No No No No No
A.3 No No No No Yes
A.4.1–2 No No No No Yes (muscle abscess)
Type B Yes Yes/no No No Yes/no
B.1 Yes No No No No
B.2 Yes No No No Yes
B.3.1–2 Yes Yes No No Yes
Type C Yes/no Yes/no Yes Yes/no –
C.1 Yes/no No Yes No –
C.2 Yes Yes Yes No –
C.3 Yes No Yes Yes –
C.4 Yes Yes Yes Yes –

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Fig. 1 Magnetic resonance imaging (MRI) of type A pyogenic coronal T1-weighted contrast-enhanced MRI showing type A.3. PS
spondylodiscitis (PS). a Sagittal T1-weighted and axial T2-weighted involving D7–D8 vertebral bodies with paravertebral abscess (ar-
MRI showing type A.1. post-operative L4–L5 discitis. b Sagittal T1- rows). d Coronal and axial contrast-enhanced MRI showing type
weighted and axial T2-weighted MRI of type A.2. PS with A.4.2. PS with bilateral intra-psoas abscesses (arrows)
involvement of both L4 and L5 vertebral bodies. c Sagittal and

Table 2 Treatment algorithm showing the treatments of choice according to the classification scheme
Classes Treatments of choice

Type A
A.1 Rigid orthosis immobilization
A.2 Rigid orthosis immobilization or percutaneous stabilization
A.3 Rigid orthosis immobilization or percutaneous stabilization
A.4.1–2 Rigid orthosis immobilization or percutaneous stabilization
Type B
B.1 Rigid orthosis immobilization or percutaneous stabilization
B.2 Rigid orthosis immobilization or percutaneous stabilization
B.3.1–2 Percutaneous or open stabilization
Type C
C.1 Rigid orthosis immobilization or percutaneous stabilization with closer clinical-radiological monitoring
C.2 Open debridement and stabilization
C.3 Open debridement and decompression
C.4 Open debridement, decompression and stabilization

• C.3: epidural abscess and acute neurological impair- and closely monitored to evaluate neurological anoma-
ment without segmental instability (Fig. 3c). lies (Table 2). Type C.2 spondylodiscitis were treated
• C.4: epidural abscess and acute neurological impair- with surgical stabilization and abscess debridement to
ment with segmental instability (Fig. 3d). avoid impending neurological damages (Table 2). When
neurological impairment occurred (C.3 and C.4), surgical
Patients without acute neurological symptoms and
decompression of neurological structures was always
segmental instability (C.1) were treated conservatively
performed, combined with segmental stabilization in the

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Fig. 2 MRI of type B destructive pyogenic spondylodiscitis (PS). L4 and L5 vertebral bodies with paravertebral abscess (arrows).
a Sagittal T1-weighted and axial T2-weighted MRI showing type B.1 c Sagittal and axial T2-weighted MRI showing type B.3 thoracic PS
PS with partial destruction of L3 vertebral body. b Sagittal and with 46.71 kyphosis
coronal contrast-enhanced MRI of type B.2 destructive PS involving

Fig. 3 MRI of type C pyogenic spondylodiscitis (PS). a Sagittal contrast-enhanced MRI showing type C.3 lumbar PS with extended
contrast-enhanced MRI and axial T2-weighted MRI of type C.1 epidural abscess (arrows) in a 53-year-old male patient presented with
lumbar PS with limited epidural abscess. b Sagittal and axial T2- acute cauda equina syndrome. d Sagittal and axial T2-weighted MRI
weighted MRI showing type C.2 lumbar PS with limited epidural of type C.4 thoracic PS in a 68-year-old female patient presented with
abscess (arrows) and significant bone destruction. c Sagittal and axial acute paraplegia

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same procedure if biomechanical stability was jeopar- Etiological diagnosis was assessed in about ’ of all
dized (Table 2). patients [190 patients; 76.00%; 95% CI (68.91–82.21)].
Observed sensibility of blood culture, CT-guided biopsy
Statistical analysis and surgical biopsy was 57.64% [95% CI (49.13–65.82)],
46.27% [95% CI (34.00–58.88)] and 60.00% [95% CI
Baseline demographic and clinical onset characteristics (44.33–74.30)], respectively. Staphylococcus aureus was
were assessed using independent-sample t tests for con- the most frequently isolated causative agent [70 patients;
tinuous variables and v2 tests for frequency variables. 28.00%; 95% CI (20.97–36.11)]. Other commonly isolated
Analysis of variance was used to assess differences in microorganisms were Staphylococcus epidermidis,
clinical outcomes across follow-up, and p values 0.05 or Escherichia coli, and Klebsiella pneumoniae. 12 patients
less were considered significant. Continuous variables are [4.80%; 95% CI (1.95–9.63)] were infected by Methicillin-
presented as mean ± standard error. Frequency data are resistant Staphylococcus aureus (MRSA). 19 patients
presented as counts and percentages. Epi Info statistic [7.60%; 95% CI (3.75–13.69)] had polymicrobial infec-
software, version 7 (CDC, Atlanta, GA, USA), was used tions (Table 3).
for data analysis. 62 patients developed PS after surgical procedures
[24.80%; 95% CI (18.61–31.98)]. Direct inoculation of
causative agents during spine invasive procedures occurred
Results in 45 patients [18.00%; 95% CI (12.51–24.46)].
Type A spondylodiscitis occurred in 84 cases (33.60%).
A total of 250 patients (161 men and 89 women) were Types A.1 and A.2 included 11 (13.09%) and 28 (33.33%)
treated at our University Hospital from January 2008 to patients, respectively. Paravertebral abscesses (type A.3)
January 2015. Average age was 64.98 ± 0.97, moreover, were reported in 33 patients (39.29%), whereas intramus-
age distribution showed a significant peak in the cular abscesses (type A.4) occurred in 12 patients
60–75 years of age group. Average diagnostic delay was (14.29%). Among type A cases, 74 patients (88.10%) were
49.90 ± 5.53 days from symptoms onset. Most common prescribed 24/7 rigid orthosis immobilization, whereas 10
symptoms at diagnosis were localized spinal pain [236 patients (11.90%) underwent posterior percutaneous
patients; 94.40%; 95% CI (89.68–97.21)] and fever [159 stabilization.
patients; 63.60%; 95% CI (55.80–70.97)]. Limbs radiating 46 cases (18.40%) were classified as type B destructive
pain and weight loss were referred less frequently [106 spondylodiscitis. Segmental stability was preserved (types
patients; 42.40%; 95% CI (35.04–50.43) and 84 patients; B.1 and B.2) in 17 cases (36.96%). 29 patients (63.04%)
26.30%; 95% CI (26.30–41.40)]. 56 patients presented with presented segmental instability (type B.3) and 20 of them
neurological deficits at diagnosis [22.40%; 95% CI needed open surgical fixation, whereas 9 patients under-
(16.43–29.53)] (Fig. 4). Lumbar spine was the most com- went percutaneous stabilization.
monly affected [184 patients; 73.60%; 95% CI 120 cases (48.00%) were classified as type C spondy-
(66.29–80.16)] with peaks at L3–L5 levels. Other fre- lodiscitis with epidural abscesses or neurological impair-
quently involved levels were C5–C6 for cervical spine and ment. Among type C cases, 49 patients (40.83%) had no
D8–D10 for thoracic spine. No localizations were observed neurological deficits neither segmental instability (type
at C0–C3 levels. C.1), thus they were treated conservatively. Type C.2

Fig. 4 Frequency of most

common onset symptoms
observed at diagnosis in overall
population

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Table 3 Causative agents cultured from blood and/or tissue speci- Discussion
mens in overall population
Causative agents Prevalence n (%) Despite considerably improved diagnostic efficiency, there
are no standardized orthopedic treatment guidelines for
Staphylococcus aureus 70 (28.00)
pyogenic spondylodiscitis due to heterogeneous clinical
Staphylococcus epidermidis 36 (14.40)
data available in literature, often based on small patient
Escherichia coli 17 (6.80)
populations [16]. Actually, few standardized treatments are
Klebsiella pneumoniae 14 (5.60) suggested but without prospective randomized controlled
MRSA 12 (4.80) trials the level of evidence for treatment recommendations
Polymicrobial 19 (7.60) remains low [18]. Therefore, a classification of PS based on
clinical and radiological features with a standard treatment
algorithm can be very useful to spine surgeons facing this
pathology.
included 15 patients (12.50%) that underwent surgical Clinical onset of pyogenic spondylodiscitis is typically
stabilization and abscess debridement. 30 patients nonspecific and paucisymptomatic. Thus, differential
(25.00%) with acute neurological deficits without seg- diagnosis with degenerative spine pathologies is often
mental instability (type C.3) underwent surgical decom- difficult. Different reviews reported a mean diagnostic
pression of neurological structures. Open surgical delay of 90 days [6, 7]. For this reason, early diagnosis
stabilization was combined in the same procedure (type should be the first aim of clinical approach to PS. Early
C.4) in 26 cases (21.67%). diagnosis is based on a high level of suspicion with
Average time of hospitalization was 51.94 ± 3.00 days. emphasis on patients presenting acute and localized spinal
Full healing from infection was achieved in 232 patients pain combined with fever and known risk factors for
with an overall healing rate of 92.80% [95% CI infectious diseases. About 1/3 of all patients can be
(87.17–96.49)]. 14 relapses have been reported during apyretic at clinical onset hindering the differential diag-
follow-up with an overall recurrence rate of 5.60% [95% nosis with non-infectious spine pathologies. Contrast-en-
CI (2.67–10.67)]. hanced MRI showed the highest diagnostic sensibility and
Clinical outcomes for each class are shown in Table 4. provides a baseline picture on biomechanical stability and
A total of 140 patients (56.00%) were treated conserva- neurological structures [19, 20]. When MRI is promptly
tively. Average time of rigid orthosis immobilization was performed, impending neurological lesions or structural
218.17 ± 9.89 days. Among 110 cases (44.00%) treated damages can be detected earlier allowing the choice of less
surgically, 4 patients underwent procedure-related com- invasive treatments. CT may be useful when there are
plications, however, none of them reported permanent doubts on osteonecrosis extension or biomechanical sta-
damages. bility. There are no pathognomonic laboratory markers but
Self-reported VAS scores consistently decreased across CRP, ESR and WBC anomalies should raise the level of
time points in all classes reaching an average value of suspicious.
0.65 ± 0.21 at 2 years from diagnosis (Fig. 5). Similarly, The high healing rate and low recurrence rate observed
mental and physical components of SF-12 questionnaire in this study first demonstrate that a multidisciplinary
increased significantly (Fig. 6). approach to PS is the best choice. Early administration of
Residual chronic back pain occurred in 27 patients specific antibiotics prevents further damages and diffusion
(10.80%), whereas 13 patients (5.20%) showed residual of causative agent. While waiting for the microbiological
neurological deficits. Overall mortality was 4.80% [95% CI results, an empirical therapy can be started in severe cases
(3.33–6.48)]. [17]. According to 2015 IDAS guidelines, intravenous

Table 4 Clinical outcomes

Clinical outcomes Type A (n = 84) Type B (n = 46) Type C (n = 120)
observed at 2-year follow-up for
each type of PS Prevalence n (%) 84 (33.60) 46 (18.40) 120 (48.00)
Healing rate n (%) 81 (96.43) 43 (93.48) 108 (90.00)
Residual chronic pain n (%) 9 (10.71) 5 (10.87) 13 (10.83)
Recurrence rate n (%) 8 (9.52) 2 (4.35) 4 (3.33)
Mortality n (%) 3 (3.57) 3 (6.52) 6 (5.00)

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Fig. 5 Self-reported Visual

Analog Scale (VAS) scores are
shown at diagnosis and at 1, 3,
6, 12, and 24 months post-
diagnosis. VAS scores
significantly decreased in all
classes across time points
showing the efficacy of the
proposed treatment algorithm in
controlling pain

Fig. 6 Pre- and post-treatment short-form (SF-12) mental component all classes across follow-up demonstrating a good restoration of
(left) and physical component (right) scores are shown at 1, 3, 6, 12, patients’ quality of life
and 24 months after diagnosis. Both scores significantly increased in

therapy should be administrated for at least 4 weeks fol- 7 months. Residual chronic back pain observed in 10.80%
lowed by oral course until normalization of laboratory and of our patients is mostly attributable to non-surgically
radiological markers of infection [17]. On the other hand, treated patients with postinfection kyphosis or
surgical debridement may be necessary to eradicate the pseudoarthrosis.
infection [9, 10]. The high efficiency of microbiological Since January 2010, percutaneous posterior screw-rod
isolation techniques observed in this study (76.00%) also instrumentation bridging the infected level has been used
derives from the close collaboration with infectious dis- as safe and effective alternative approach to prolonged
eases specialists. In fact, blood culture when adequately rigid bracing for single-level thoraco-lumbar PS. A retro-
collected, especially before and after invasive procedures, spective cohort study demonstrated faster recovery and
showed higher sensibility then reported in literature data. improved quality of life associated with minimally invasive
55 patients (22.00%) needed surgical biopsy. treatment [24]. Posterior percutaneous stabilization is also
When there are no neurological deficits and no signifi- indicated in patients with biomechanical instability and
cant instability, PS can be managed without surgical mild segmental kyphosis (type B.3.1).
intervention (types A.1–4, B.1–2 and C.1). Lumbar When acute neurological impairment or severe kyphosis
epidural abscess may be approached with a conservative occur (types B.3.2, C.3–4), open surgical approach is
treatment only if there is no evidence for cauda equina or mandatory. Emergency decompression is indicated if
conus dysfunction [9, 22]. Immobilization is necessary to complete plegia develops [16]. Decompression and
maintain spinal stability until bony ankylosis occurs instrumented spinal stabilization should be performed in
[9, 10]. However, spontaneous ankylosis requires the same procedure if neurological deficit exists (type C.4).
6–24 months and may not take place at all [23]. In our On the contrary, if instability and pain are present in a
population, average time of immobilization was about patient without neurological impairment (types B.3 and

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