Spine

Anterior cervical discectomy and fusion complications

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Anterior cervical discectomy and fusion complications

ACD is known to be associated with a higher risk either of residual increased neck and shoulder pain 1) 2) or of developing a postoperative kyphotic deformity of the cervical spine 3) ; and this, in turn, can lead to the development of degenerative changes at adjacent levels

A 2-page survey was distributed to attendees at the 2015 Cervical Spine Research Society (CSRS) meeting. Respondents were asked to categorize 18 anterior cervical discectomy and fusion-related adverse events as either: “common and acceptable,” “uncommon and acceptable,” “uncommon and sometimes acceptable,” or “uncommon and unacceptable.” Results were compiled to generate the relative frequency of these responses for each complication. Responses for each complication event were also compared between respondents based on practice location (US vs. non-US), primary specialty (orthopedics vs. neurosurgery) and years in practice.

Of 150 surveys distributed, 115 responses were received (76.7% response rate), with the majority of respondents found to be US-based (71.3%) orthopedic surgeons (82.6%). Wrong level surgery, esophageal injury, retained drain, and spinal cord injury were considered by most to be unacceptable and uncommon complications. Dysphagia and adjacent segment disease occurred most often, but were deemed acceptable complications. Although surgeon experience and primary specialty had little impact on responses, practice location was found to significantly influence responses for 12 of 18 complications, with non-US surgeons found to categorize events more toward the uncommon and unacceptable end of the spectrum as compared with US surgeons.

These results serve to aid communication and transparency within the field of spine surgery, and will help to inform future quality improvement and best practice initiatives 4).

Systematic reviews and meta-analysis

A systematic review of the literature was performed in PubMed/MEDLINE, Embase, and the Cochrane Library for observational studies published between January 1996 and March 2023 and reporting postoperative complications associated with ACDF. Randomized controlled trials and interventional investigations were not included in this study. Meta-regression was also performed using generalized linear mixed models with a binomial probability distribution on various potential predicting factors.

A total of 222 studies reporting the rate of complications associated with ACDF in 50,584 patients were included in the present study. The overall postoperative complication rate was 16%. The most common complications were excessive neck swelling (11.3%), pseudarthrosis (10.0%), dysphagia (9.5%), cage/graft subsidence (9.4%), worsening myelopathy (7.7%), and hoarseness (2.3%). Nonhome discharge, readmission, and mortality rates were 13.8%, 3.7%, and 0.1%, respectively. Based on meta-regression, more levels of fusion and increased age were significantly associated with an increase in the pooled overall postoperative complication rate. Moreover, the rate of some postoperative complications was significantly associated with several perioperative characteristics.

This study is the most extensive meta-analysis conducted on the existing literature regarding ACDF-related complications and potential risk factors. However, future high-quality prospective studies or clinical trials are highly required to provide further evidence and validate the present findings 5).

This study provides a valuable and timely synthesis of ACDF-related complications in clinical practice. It successfully quantifies complication rates and identifies key risk factors, which can guide patient counseling and surgical planning. However, its findings should be interpreted in light of the limitations of observational data and study heterogeneity. Future prospective studies and RCTs are needed to validate these associations and explore modifiable risk factors more thoroughly.

Narrative Reviews

In multiple studies, overall morbidity rates for ACDF varied from 13.2% to 19.3%. These included in descending order; dysphagia (1.7%-9.5%), postoperative hematoma (0.4%-5.6% (surgery required in 2.4% of 5.6%), with epidural hematoma 0.9%), exacerbation of myelopathy (0.2%-3.3%), symptomatic recurrent laryngeal nerve palsy (0.9%-3.1%), cerebrospinal fluid (CSF) leak (0.5%-1.7%), wound infection (0.1-0.9%-1.6%), increased radiculopathy (1.3%), Horner’s syndrome (0.06%-1.1%), respiratory insufficiency (1.1%), esophageal perforation (0.3%-0.9%, with a mortality rate of 0.1%), and instrument failure (0.1%-0.9%). There were just single case reports of an internal jugular veing occlusion and a phrenic nerve injury. Pseudarthrosis occurred in ACDF and was dependant on the number of levels fused; 0-4.3% (1-level), 24% (2-level), 42% (3 level) to 56% (4 levels). The reoperation rate for symptomatic pseudarthrosis was 11.1%. Readmission rates for ACDF ranged from 5.1% (30 days) to 7.7% (90 days postoperatively).

Conclusions: Complications attributed to ACDF included; dysphagia, hematoma, worsening myelopathy, recurrent laryngeal nerve palsy, CSF leaks, wound infection, radiculopathy, Horner’s Syndrome, respiratory insufficiency, esophageal perforation, and instrument failure. There were just single case reports of an internal jugular vein thrombosis, and a phrenic nerve injury. As anticipated, pseudarthrosis rates increased with the number of ACDF levels, ranging from 0-4.3% for 1 level up to 56% for 4 level fusions 6)

Retrospective observational cohort studies

Twenty-seven patients with 54 levels and a mean age of 50.8 years were enrolled between January 2005 and August 2006. They underwent ACDF using polyetheretherketone cages packed with demineralized bone matrix without plate fixation at two contiguous levels. Mean follow-up period was 25.5 months (range, 13-60). Clinical outcome was evaluated using two Visual Analog Scales and the Neck Disability Index (NDI). We assessed fusion, regional alignment (RA) of the operated levels and cervical global alignment (GA) preoperatively in the immediate 1-week postoperative period and at the final follow-up. An interspinous distance ≥2 mm was used as an indicator of pseudoarthrosis at each level.

Findings: All patients showed improvements in clinical outcome, with 96% of patients showing mild NDI scores (<14). Radiological solid fusion was obtained at 48 of 54 levels (88.9%) and in 21 of 27 patients (77.8%). Lower cervical levels were significantly more vulnerable to pseudoarthrosis (100%). Fusion rate had no significant correlation with outcome (p > 0.05). RA of the operated levels was improved at the final follow-up compared with preoperatively in 76% of patients, although it had decreased compared with the immediate postoperative period due to subsidence in 84% of patients. In total, 80.8% of patients showed improvements in GA. Furthermore, improvements in RA showed a significant positive correlation with those in GA (p = 0.001), although improvement in RA and GA did not correlate significantly with clinical outcome (p > 0.05).

Conclusions: Though some degree of subsidence occurred in most cases, RA had improved at the last follow-up compared with preoperatively, which contributed to the significant improvement in GA. However, improvement of RA and GA was not correlated with outcomes 7)

Vocal cord palsy

see Vocal cord palsy after anterior cervical discectomy.

Cervical adjacent segment disease

Cervical adjacent segment disease

Hoarseness

Hoarseness, approximately in 5% 8).

Dysphagia

Dysphagia after anterior cervical discectomy

Postoperative hemorrhage

see Postoperative hemorrhage after anterior cervical discectomy and fusion

Cerebrospinal fluid fistula after anterior cervical discectomy and fusion

Cerebrospinal fluid fistula after anterior cervical discectomy and fusion.

Pharyngoesophageal perforation

see Esophageal perforation.

Spinal subdural hematoma

A spinal subdural hematoma is a rare clinical entity with considerable consequences without prompt diagnosis and treatment. Throughout the literature, there are limited accounts of spinal subdural hematoma formation following spinal surgery. This report is the first to describe the formation of a spinal subdural hematoma in the thoracic spine following surgery at the cervical level. A 53-year-old woman developed significant paraparesis several hours after anterior cervical discectomy and fusion of C5-6. Expeditious return to operating room for anterior cervical revision decompression was performed, and the epidural hematoma was evacuated without difficulty. Postoperative imaging demonstrated a subdural hematoma confined to the thoracic level, and the patient was returned to the operating room for a third surgical procedure. Decompression of T1-3, with evacuation of the subdural hematoma was performed. Postprocedure, the patient’s sensory and motor deficits were restored, and, with rehabilitation, the patient gained functional mobility. Spinal subdural hematomas should be considered as a rare but potential complication of cervical discectomy and fusion. With early diagnosis and treatment, favorable outcomes may be achieved 9).

Carotid artery compression

Legatt et al., report herein a case of anterior cervical discectomy and fusion (ACDF) surgery in which findings on somatosensory evoked potential (SSEP) monitoring led to the correction of carotid artery compression in a patient with a vascularly isolated hemisphere (no significant collateral blood vessels to the carotid artery territory). The amplitude of the cortical SSEP component to left ulnar nerve stimulation progressively decreased in multiple runs, but there were no changes in the cervicomedullary SSEP component to the same stimulus. When the lateral (right-sided) retractor was removed, the cortical SSEP component returned to baseline. The retraction was then intermittently relaxed during the rest of the operation, and the patient suffered no neurological morbidity. Magnetic resonance angiography demonstrated a vascularly isolated right hemisphere. During anterior cervical spine surgery, carotid artery compression by the retractor can cause hemispheric ischemia and infarction in patients with inadequate collateral circulation. The primary purpose of SSEP monitoring during ACDF surgery is to detect compromise of the dorsal column somatosensory pathways within the cervical spinal cord, but intraoperative SSEP monitoring can also detect hemispheric ischemia. Concurrent recording of cervicomedullary SSEPs can help differentiate cortical SSEP changes due to hemispheric ischemia from those due to compromise of the dorsal column pathways. If there are adverse changes in the cortical SSEPs but no changes in the cervicomedullary SSEPs, the possibility of hemispheric ischemia due to carotid artery compression by the retractor should be considered 10).

Heterotopic Ossification

Heterotopic ossification (HO) has been reported following total hip, knee, cervical arthroplasty, and lumbar arthroplasty, as well as following posterolateral lumbar fusion using recombinant human morphogenetic protein 2 (rhBMP-2). Data regarding HO following anterior cervical discectomy and fusion (ACDF) with rhBMP-2 are sparse. A subanalysis was done of the prospective, multicenter, investigational device exemption trial that compared rhBMP-2 on an absorbable collagen sponge (ACS) versus allograft in ACDF for patients with symptomatic single-level cervical degenerative disc disease.

To assess differences in types of HO observed in the treatment groups and effects of HO on functional and efficacy outcomes, clinical outcomes from previous disc replacement studies were compared between patients who received rhBMP-2/ACS versus allograft. Rate, location, grade, and size of ossifications were assessed preoperatively and at 24 months, and correlated with clinical outcomes. RESULTS Heterotopic ossification was primarily anterior in both groups. Preoperatively in both groups, and including osteophytes in the target regions, HO rates were high at 40.9% and 36.9% for the rhBMP-2/ACS and allograft groups, respectively (p = 0.350). At 24 months, the rate of HO in the rhBMP-2/ACS group was higher than in the allograft group (78.6% vs 59.2%, respectively; p < 0.001). At 24 months, the rate of superior-anterior adjacent-level Park Grade 3 HO was 4.2% in both groups, whereas the rate of Park Grade 2 HO was 19.0% in the rhBMP-2/ACS group compared with 9.8% in the allograft group. At 24 months, the rate of inferior-anterior adjacent-level Park Grade 2/3 HO was 11.9% in the rhBMP-2/ACS group compared with 5.9% in the allograft group. At 24 months, HO rates at the target implant level were similar (p = 0.963). At 24 months, the mean length and anteroposterior diameter of HO were significantly greater in the rhBMP-2/ACS group compared with the allograft group (p = 0.033 and 0.012, respectively). Regarding clinical correlation, at 24 months in both groups, Park Grade 3 HO at superior adjacent-level disc spaces significantly reduced range of motion, more so in the rhBMP-2/ACS group. At 24 months, HO negatively affected Neck Disability Index scores (excluding neck/arm pain scores), neurological status, and overall success in patients in the rhBMP-2/ACS group, but not in patients in the allograft group.

Implantation of rhBMP-2/ACS at 1.5 mg/ml with polyetheretherketone spacer and titanium plate is effective in inducing fusion and improving pain and function in patients undergoing ACDF for symptomatic single-level cervical degenerative disc disease. At 24 months, the rate and dimensions (length and anteroposterior diameter) of HO were higher in the rhBMP-2/ACS group. At 24 months, range of motion was reduced, with Park Grade 3 HO in both treatment groups. The impact of Park Grades 2 and 3 HO on Neck Disability Index success, neurological status, and overall success was not consistent among the treatment groups. The study data may offer a deeper understanding of HO after ACDF and may pave the way for improved device designs 11).

Cage subsidence

see Cage subsidence

Anterior cervical pseudarthrosis

Anterior cervical pseudarthrosis.

Case series

Analysis of 1000 consecutive patients undergoing Anterior cervical discectomy and fusion (ACDF) in an outpatient setting demonstrated surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in 4-hour ASC PACU window. Comparison with inpatient ACDF surgery cohort demonstrated similar results, highlighting that ACDF can be safely performed in an outpatient ambulatory surgery setting without compromising surgical safety. To decrease cost of care, surgeons can safely consider performing 1- and 2-level ACDF in an ASC environment 12).

A retrospective case series of 37 patients, paying special attention to immediate complications related to the use of mechanical retraction of soft tissue (dysphagia, dysphonia, esophageal lesions and local hematoma); and a comparative analysis of the outcomes after changes in the retraction method.

All selected cases had a positive neurological symptom response in relation to neuropathic pain. Dysphagia and dysphonia were found during the first 72 h in 94.1% of the cases in which automatic mechanical retraction was used for more than one hour during the surgical procedure. A radical change was noted in the reduction of the symptoms after the use of only manual protective blades without automatic mechanical retraction: 5.1% dysphagia and 0% dysphonia in the immediate post-operative period, P = 0.001.

Soft tissue damage due to the use of automatic retractors in MACDF is not minor and leads to general discomfort in the patient in spite of good neurological results. These problems most often occur when automatic retractors are used continuously for more than 1 hour, as well as when they are used in multiple levels. Dysphagia, dysphonia and local pain decreased with the use of transient manual blades for retraction, and with intermittent release following minimally invasive principles 13).

1)

LUNSFORD LD, BISSONETTE DJ, JANNETTA PJ, SHEPTAK PE, ZORUB DS. Anterior surgery for cervical disc dis- ease: Part-1 treatment of lateral cervical disc herni- ation in 253 cases. J Neurosurg 1980; 53: 1-11.
2)

LUNSFORD LD, BISSONETTE DJ, ZORUB DS. Anterior surgery for cervical disc disease: Part-2 treatment of cervical spondylotic myelopathy in 32 cases. J Neurosurg 1980; 53: 12-19.
3)

ABD-ALRAHMAN N, DOKMAK AS, ABOU-MADAWI A. An- terior cervical discectomy (ACD) versus anterior cervical fusion (ACF), clinical and radiological outcome study. Acta Neurochir (Wien) 1999; 141: 1089-1092.
4)

Wilson JR, Radcliff K, Schroeder G, Booth M, Lucasti C, Fehlings M, Ahmad N, Vaccaro A, Arnold P, Sciubba D, Ching A, Smith J, Shaffrey C, Singh K, Darden B, Daffner S, Cheng I, Ghogawala Z, Ludwig S, Buchowski J, Brodke D, Wang J, Lehman RA, Hilibrand A, Yoon T, Grauer J, Dailey A, Steinmetz M, Harrop JS. Frequency and Acceptability of Adverse Events After Anterior Cervical Discectomy and Fusion: A Survey Study From the Cervical Spine Research Society. Clin Spine Surg. 2018 Apr 27. doi: 10.1097/BSD.0000000000000645. [Epub ahead of print] PubMed PMID: 29708891.
5)

Tavanaei R, Ansari A, Hatami A, Heidari MJ, Dehghani M, Hajiloo A, Khorasanizadeh M, Margetis K. Postoperative complications of anterior cervical discectomy and fusion: A comprehensive systematic review and meta-analysis. N Am Spine Soc J. 2025 Feb 8;21:100596. doi: 10.1016/j.xnsj.2025.100596. PMID: 40145067; PMCID: PMC11938155.
6)

Epstein NE. A Review of Complication Rates for Anterior Cervical Diskectomy and Fusion (ACDF). Surg Neurol Int. 2019 Jun 7;10:100. doi: 10.25259/SNI-191-2019. PMID: 31528438; PMCID: PMC6744804.
7)

Moon HJ, Kim JH, Kim JH, Kwon TH, Chung HS, Park YK. The effects of anterior cervical discectomy and fusion with stand-alone cages at two contiguous levels on cervical alignment and outcomes. Acta Neurochir (Wien). 2011 Mar;153(3):559-65. doi: 10.1007/s00701-010-0879-z. Epub 2010 Dec 4. PMID: 21132445.
8)

Morpeth JF, Williams MF. Vocal fold paralysis after anterior cervical diskectomy and fusion. Laryngoscope. 2000 Jan;110(1):43-6. PubMed PMID: 10646714.
9)

Protzman NM, Kapun J, Wagener C. Thoracic spinal subdural hematoma complicating anterior cervical discectomy and fusion: case report. J Neurosurg Spine. 2015 Oct 13:1-5. [Epub ahead of print] PubMed PMID: 26460756.
10)

Legatt AD, Laarakker AS, Nakhla JP, Nasser R, Altschul DJ. Somatosensory evoked potential monitoring detection of carotid compression during ACDF surgery in a patient with a vascularly isolated hemisphere. J Neurosurg Spine. 2016 Nov;25(5):566-571. PubMed PMID: 27285667.
11)

Arnold PM, Anderson KK, Selim A, Dryer RF, Kenneth Burkus J. Heterotopic ossification following single-level anterior cervical discectomy and fusion: results from the prospective, multicenter, historically controlled trial comparing allograft to an optimized dose of rhBMP-2. J Neurosurg Spine. 2016 Sep;25(3):292-302. doi: 10.3171/2016.1.SPINE15798. Epub 2016 Apr 29. PubMed PMID: 27129045.
12)

McGirt MJ, Mehrlich M, Parker SL, Asher AL, Adamson TE. 165 ACDF in the Outpatient Ambulatory Surgery Setting: Analysis of 1000 Consecutive Cases and Comparison to Hospital Inpatient ACDF. Neurosurgery. 2015 Aug;62 Suppl 1:220. doi: 10.1227/01.neu.0000467129.12773.a3. PubMed PMID: 26182011.
13)

Ramos-Zúñiga R, Díaz-Guzmán LR, Velasquez S, Macías-Ornelas AM, Rodríguez-Vázquez M. A microsurgical anterior cervical approach and the immediate impact of mechanical retractors: A case control study. J Neurosci Rural Pract. 2015 Jul-Sep;6(3):315-9. doi: 10.4103/0976-3147.158748. PubMed PMID: 26167011; PubMed Central PMCID: PMC4481782.

Spondylodiscitis management

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Spondylodiscitis management

J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain

Latest PubMED Articles

Spondylodiscitis, requires a multidisciplinary approach for effective management. The goal is to eradicate the infection, prevent or treat complications (e.g., deformity, neurological deficits), and restore spinal stability and function.

see Spondylodiscitis treatment

Key Components of Management

1. Diagnosis

Accurate and early diagnosis is critical for effective treatment.

  • Clinical Presentation:
    • Symptoms: Back pain (most common), fever, localized tenderness, and occasionally neurological deficits.
    • Risk factors: Immunosuppression, recent surgery, infections, or intravenous drug use.
  • Laboratory Investigations:
    • Elevated inflammatory markers: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and leukocytosis.
    • Blood cultures: Identify causative organisms (positive in ~50-70% of cases).
  • Imaging:
    • MRI (gold standard): High sensitivity and specificity, detects soft tissue and bone involvement.
    • CT-guided biopsy: Essential for microbiological diagnosis when blood cultures are negative.

2. Medical Management

  • Antibiotics:
    • Empiric therapy: Cover gram-positive (e.g., *Staphylococcus aureus*), gram-negative, and anaerobic organisms.
    • Targeted therapy: Adjusted based on blood or biopsy cultures.
    • Duration: 6–12 weeks (longer for complicated cases or immunocompromised patients).
  • Supportive Measures:
    • Pain management with NSAIDs or opioids.
    • Immobilization: Bracing may reduce pain and prevent deformity in acute phases.

3. Surgical Management

Surgery is indicated in specific scenarios:

  • Indications:
    • Neurological deficits (e.g., weakness, bowel/bladder dysfunction).
    • Spinal instability or deformity (e.g., kyphosis >20°).
    • Abscess formation (e.g., epidural or paravertebral abscesses).
    • Failure of medical therapy (e.g., persistent infection despite antibiotics).
  • Techniques:
    • Minimally invasive surgery (MIS): Drainage of abscesses, debridement, stabilization.
    • Open surgery: Extensive debridement and reconstruction for severe instability or deformity.

4. Rehabilitation and Follow-Up

  • Physical Therapy: Promotes recovery of function and prevents deconditioning.
  • Regular Monitoring:
    • Clinical symptoms and inflammatory markers to assess response.
    • Follow-up imaging (MRI or CT) in unresolved cases or when complications are suspected.

Complications to Monitor

  • Neurological deficits.
  • Chronic pain or deformity.
  • Spinal instability.
  • Paraspinal abscess or septicemia.
  • Relapse of infection.

Recent Advances and Recommendations

  • Minimally Invasive Surgery (MIS):
    • Preferred when feasible, due to lower morbidity and faster recovery.
  • Imaging Advances:
    • MRI techniques can differentiate between infection and malignancy more effectively.
  • Consensus Guidelines (e.g., EANS recommendations):
    • Provide structured thresholds for surgical indications and antibiotic durations.

Challenges in Management

  • Delayed diagnosis due to non-specific symptoms.
  • Rising antimicrobial resistance.
  • Balancing the risks of surgery in medically fragile patients.

Conclusion

Spondylodiscitis management requires individualized care based on patient presentation, infection severity, and comorbidities. The integration of targeted antibiotics, timely surgical intervention when indicated, and structured follow-up ensures optimal outcomes. Ongoing research is essential to refine treatment protocols and improve patient care.

Delphi consensus studies

The de novo non-specific spinal infection managements (spondylodiscitis – SD) remains inconsistent due to varying clinical practices and a lack of high-level evidence, particularly regarding the indications for surgery.

Research question: This study aimed to develop consensus recommendations for spondylodiscitis diagnosis and spondylodiscitis management, addressing diagnostic modalities, surgical indications, and spondylodiscitis treatment strategies.

A Delphi consensus study was conducted with 26 experts from the European Association of Neurosurgical Societies (EANS). Sixtytwo statements were developed on diagnostic workup, management decisions, surgical techniques, non-surgical treatment, and follow-up and submitted to the panel of experts.

Consensus was reached on 38 of 62 statements. MRI was confirmed as the gold standard for diagnosis. Regarding surgical indications, the panel agreed that any new neurological deficit, even subtle, warrants surgical consideration. Motor deficits with a motor score (MRC) below 4 and bladder or bowel dysfunction were unanimously considered clear indications for surgery. For spinal deformity and instability, thresholds such as kyphosis >20°, scoliosis >10°, and vertebral body collapse >50% were established to guide surgical decision-making. Minimally invasive surgery (MIS) was endorsed whenever feasible, and a 12 week antibiotic treatment regimen was favored in cases of complicated infections.

This EANS consensus provides updated recommendations for spondylodiscitis management, incorporating recent evidence on improved outcomes with surgical therapy. While these guidelines offer a more structured approach to clinical decision-making, further research is required to optimize surgical timing and validate the long-term impact of these treatment strategies 1).

This study successfully tackles a clinically significant challenge by providing structured recommendations for the diagnosis and management of de novo non-specific spinal infections. While the use of the Delphi method lends credibility, the reliance on expert opinion, incomplete consensus, and limited global representation are notable limitations. Nonetheless, it serves as an important step towards standardizing care for spinal infections and highlights the urgent need for further research to validate and refine these recommendations.

Systematic review and meta-analysis

Thavarajasingam et al. aimed to compare the mortality, relapse rate, and length of hospital stay of conservative versus early surgical treatment of pyogenic spondylodiscitis. All major databases were searched for original studies, which were evaluated using a qualitative synthesis, meta-analyses, influence, and regression analyses. The meta-analysis, with an overall pooled sample size of 10,954 patients from 21 studies, found that the pooled mortality among the early surgery patient subgroup was 8% versus 13% for patients treated conservatively. The mean proportion of relapse/failure among the early surgery subgroup was 15% versus 21% for the conservative treatment subgroup. Further, it concluded that early surgical treatment, when compared to conservative management, is associated with a 40% and 39% risk reduction in relapse/failure rate and mortality rate, respectively, and a 7.75 days per patient reduction in length of hospital stay (p < 0.01). The meta-analysis demonstrated that early surgical intervention consistently significantly outperforms conservative management in relapse/failure and mortality rates, and length of stay, in patients with pyogenic spondylodiscitis 2)

Thavarajasingam et al.’s systematic review and meta-analysis provide compelling evidence that early surgical intervention significantly outperforms conservative management in pyogenic spondylodiscitis, with reductions in mortality, relapse rates, and hospital stays. However, limitations such as heterogeneity, reliance on observational data, and a lack of long-term outcome evaluation temper the strength of its conclusions. Future studies should address these gaps to enhance the robustness and applicability of the findings across diverse patient populations and healthcare environments.

Systematic review

A population-based study from Denmark showed that the incidence of spondylodiscitis rose from 2.2 to 5.8 per 100 000 persons per year over the period 1995-2008; the age-standardized incidence in Germany has been estimated at 30 per 250 000 per year on the basis of data from the Federal Statistical Office (2015). The early diagnosis and treatment of this condition are essential to give the patient the best chance of a good outcome, but these are often delayed because it tends to present with nonspecific manifestations, and fever is often absent.

Herren et al published an article based on a systematic search of Medline and the Cochrane Library for the period January 2009 to March 2017. Of the 788 articles identified, 30 publications were considered.

The goals of treatment for spondylodiscitis are to eliminate infection, restore functionality of the spine, and relieve pain. Magnetic resonance imaging (MRI) remains the gold standard for the radiological demonstration of this condition, with 92% sensitivity and 96% specificity. It also enables visualization of the spatial extent of the infection and of abscess formation (if present). The most common bacterial cause of spondylodiscitis in Europe is Staphylococcus aureus, but tuberculous spondylodiscitis is the most common type worldwide. Antibiotic therapy is a pillar of treatment for spondylodiscitis and should be a part of the treatment in all cases. Neurologic deficits, sepsis, an intraspinal empyema, the failure of conservative treatment, and spinal instability are all indications for surgical treatment.

The quality of life of patients who have been appropriately treated for spondylodiscitis has been found to be highly satisfactory in general, although back pain often persists. The risk of recurrence increases in the presence of accompanying illnesses such as diabetes mellitus, renal failure, or undrained epidural abscesses 3)

Literature review with clinical recommendations

Five influential studies on PS that have the potential to shape current practice in spinal infections were selected and reviewed. Each study was chosen for its contribution to a critical phase in PS management: diagnosis, imaging, surgical vs conservative treatment, and antibiotic duration. Recommendations were graded as strong or conditional following the GRADE methodology.

Five studies were highlighted. Article 1: Pluemer et al introduced the Spinal Infection Treatment Evaluation (SITE) Score, a novel scoring tool for standardizing treatment decision-making. Conditional recommendation to incorporate the SITE Score or SISS Score for improved treatment outcomes. Article 2: Maamari et al conducted a meta-analysis comparing imaging modalities, with conditional recommendation to consider 18F-FDG PET/CT to diagnosis PS as an adjunct to MRI which remains the gold standard. Article 3: Thavarajasingam et al demonstrated the potential survival benefit of early surgery in specific PS cases, leading to a strong recommendation for early intervention in appropriate patients. Article 4: Neuhoff et al compared conservative and surgical treatments in well-resourced settings, concluding a strong recommendation for early surgery in appropriate patients. Article 5: Bernard et al evaluated antibiotic treatment duration, with a conditional recommendation for a 6-week course in confirmed cases, based on comparable efficacy to a 12-week regimen.

Management of PS remains complex and varied. This perspective provides spine surgeons with evidence-based recommendations to enhance standardization and effectiveness in clinical practice 4).

The study represents a valuable effort to synthesize impactful research on PS management and translate it into actionable recommendations. However, its narrow scope, reliance on conditional recommendations, and limited discussion of implementation challenges restrict its immediate applicability in diverse settings. Future efforts should expand the evidence base, address variability in resources, and validate the proposed guidelines to enhance their utility in standardizing and improving care for pyogenic spondylodiscitis.

1)

Kramer A, Thavarajasingam SG, Neuhoff J, Davies B, Barbagallo G, Debono B, Depreitere B, Eicker SO, Gabrovsky N, Gandia-Gonzalez ML, Ivanov M, Kaiser R, Kaprovoy S, Konovalov N, Lafuente J, Maciejczak A, Meyer B, Pereira P, Petrova Y, Peul WC, Reizinho C, Ryang YM, Sampron N, Schär R, Tessitore E, Thomé C, Timothy J, Vleggeert-Lankamp C, Demetriades AK, Shiban E, Ringel F. Diagnosis and management of de novo non-specific spinal infections: European Association of Neurosurgical Societies (EANS) Spine Section Delphi consensus recommendations. Brain Spine. 2024 Dec 31;5:104178. doi: 10.1016/j.bas.2024.104178. PMID: 39866360; PMCID: PMC11763570.
2)

Thavarajasingam SG, Vemulapalli KV, Vishnu K S, Ponniah HS, Vogel AS, Vardanyan R, Neuhoff J, Kramer A, Shiban E, Ringel F, Demetriades AK, Davies BM. Conservative versus early surgical treatment in the management of pyogenic spondylodiscitis: a systematic review and meta-analysis. Sci Rep. 2023 Sep 20;13(1):15647. doi: 10.1038/s41598-023-41381-1. PMID: 37730826; PMCID: PMC10511402.
3)

Herren C, Jung N, Pishnamaz M, Breuninger M, Siewe J, Sobottke R. Spondylodiscitis: Diagnosis and Treatment Options. Dtsch Arztebl Int. 2017 Dec 25;114(51-52):875-882. doi: 10.3238/arztebl.2017.0875. PMID: 29321098; PMCID: PMC5769318.
4)

Bigdon SF, Vialle E, Dandurand C, Scherer J, Camino-Willhuber G, Joaquim AF, Chhabra HS, El-Sharkawi M, Bransford R, Fisher CG, Schnake KJ, Schroeder GD; AO KF Trauma and Infection Members. Streamlining the Journey of Research Into Clinical Practice: Making Your Patients and Practice Flourish Evaluation and Treatment of Pyogenic Spondylodiscitis of the Spine: AO Spine Knowledge Forum Trauma and Infection. Global Spine J. 2025 Jan 24:21925682251316814. doi: 10.1177/21925682251316814. Epub ahead of print. PMID: 39852953; PMCID: PMC11760070.

Spinal schwannoma

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Spinal schwannoma

J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain

Latest Pubmed Articles

Definition

Spinal schwannomas are well-described slow growing benign spinal tumors of the peripheral nervous system, arising from Schwann cells.

Epidemiology

see Spinal schwannoma epidemiology.

Classification

see Spinal Schwannoma Classification.

Associations

The vast majority of spinal schwannomas are solitary and sporadic (95%) 10.

However, there is an association with neurofibromatosis type 2 (NF2). In patients with NF2, almost all spinal nerve root tumors are schwannomas or mixed tumors. In a young adult without the NF2 mutation, the finding of multiple schwannomas may meet the criteria for schwannomatosis.

Pathology

Antoni A and Antoni B tissue.

Clinical features

Patients with nonsyndromic spinal schwannoma usually present to hospital with local pain and neurological deficit that exacerbate over time.

Early symptoms are often radicular.

Neurological deficits develop late.

Tumor may cause radiculopathy, myelopathy, radiculomyelopathy or cauda equina syndrome.

Diagnosis

Spinal schwannoma diagnosis

Differential diagnosis

Spinal Schwannoma differential diagnosis

Treatment

see Spinal schwannoma treatment.

Outcome

Spinal schwannoma recurrence is rare after total excision (except in neurofibromatosis).

The risk for motor deficit is higher for schwannomas than for neurofibromas, for cervical vs. lumbar tumors, and for cervical tumors wiyh extradural extension.

Systematic Review and Meta-Analysis

Alvarez-Crespo et al. conducted a systematic review and meta-analysis under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of bibliographic databases from January 1, 2001, to May 31, 2021, yielded 4489 studies. Twenty-six articles were included in our final qualitative systematic review and quantitative meta-analysis.

Analysis of 2542 adult patients’ data from 26 included studies showed that 53.5% were male, and the mean age ranged from 35.8 to 57.1 years. The most common tumor location was the cervical spine (34.2%), followed by the thoracic spine (26.2%) and the lumbar spine (18.5%). Symptom severity was the most common indicator for surgical treatment, with the most common symptoms being segmental back pain, sensory/motor deficits, and urinary dysfunction. Among all patients analyzed, 93.8% were treated with gross total resection, which was associated with a better prognosis and less chance of recurrence than subtotal resection. The posterior approach was the most common (87.4% of patients). The average operative time was 4.53 hours (95% confidence interval [CI], 3.18-6.48); the average intraoperative blood loss was 451.88 mL (95% CI, 169.60-1203.95). The pooled follow-up duration was 40.6 months (95% CI, 31.04-53.07). The schwannoma recurrence rate was 5.3%. Complications were particularly low and included cerebrospinal fluid leakage, wound infection, and sensory-motor deficits. Most of the patients experienced complete recovery or significant improvement of preoperative neurological deficits and pain symptoms.

The analysis suggests that segmental back pain, sensory/motor deficits, and urinary dysfunction are the most common symptoms of spinal schwannomas. Surgical resection is the treatment of choice with overall good reported outcomes and particularly low complication rates. gross total resection offers the best prognosis with the slightest chance of tumor recurrence and minimal risk of complications 1).

Case series

see Spinal Schwannoma Case Series.

Case reports

see Spinal Schwannoma Case Reports.

1)

Alvarez-Crespo DJ, Conlon M, Kazim SF, Skandalakis GP, Bowers CA, Chhabra K, Tarawneh O, Arbuiso S, Cole KL, Dominguez J, Dicpinigaitis AJ, Vellek J, Thommen R, Bisson EF, Couldwell WT, Cole CD, Schmidt MH. Clinical Characteristics and Surgical Outcomes of 2542 Patients with Spinal Schwannomas: A Systematic Review and Meta-Analysis. World Neurosurg. 2024 Feb;182:165-183.e1. doi: 10.1016/j.wneu.2023.11.090. Epub 2023 Nov 24. PMID: 38006933.

DISC care

by

DISC care

https://neosurgery.com/project/spine/

Prospective multicenter cohort clinical investigation

The aim of this prospective multicenter cohort clinical investigation was to evaluate the performance and safety of a new hernia blocking system (HBS), implanted after a limited discectomy, for recurrent lumbar disc herniation prevention.

Prospective, multicenter (6 sites), cohort clinical investigation. Thirty patients with a postero-lateral disc herniation between L4-S1 and large annular defects (> 6 mm wide), who underwent a limited discectomy and were treated with a new HBS (DISC care, NEOS Surgery S.L.), were included.

Godino et al. presents details about the investigational device, its surgical technique, intraoperative parameters, and up to 6 months follow-up outcomes. The primary endpoint of the study was to assess the incidence of early symptomatic reherniation. In addition, disc height, leg and back pain (NRS 0-10), Oswestry Disability Index (ODI), quality of life (EQ-5D-5L) and device safety, were evaluated.

Clinicaltrials: gov: NCT04188236; date: 27th November 2019.

Thirty patients (43.3% female, 41.7 ± 10.9 years) were implanted with the device under evaluation in a mean of 16 ± 9.6 min. Six months after surgery, no symptomatic reherniation was detected and disc height was maintained in all patients included. All patients had a significant reduction in leg pain (> 2 points in the NRS), 92.9% improved > 15 points in the ODI and 82.6% significantly improved their quality of life (≥ 12 points in EQ VAS score). No product-related serious adverse events nor reoperations occurred.

The implantation of an HBS is a feasible and safe procedure that prevents early disc herniation recurrence in patients at high risk of reherniation 1).

Strengths of the Study Innovative Focus: The study introduces a new hernia blocking system (HBS), addressing a critical need in spine surgery—preventing recurrent lumbar disc herniation in high-risk patients. This innovation holds promise for improving post-discectomy outcomes.

Study Design: The prospective, multicenter cohort design strengthens the reliability of the findings by incorporating diverse surgical teams and patient demographics across six institutions. Such an approach minimizes potential biases from single-center studies.

Clear Methodology: The inclusion criteria are well-defined, focusing on patients with large annular defects and specific levels of herniation (L4-S1). Additionally, the assessment endpoints are clinically relevant, including reherniation rates, pain (NRS), disability (ODI), and quality of life (EQ-5D-5L).

Safety and Efficacy: The absence of symptomatic reherniation and maintenance of disc height at six months are significant outcomes, especially given the known challenges of recurrent herniation in this patient cohort. The lack of product-related serious adverse events and reoperations further supports the safety of the HBS.

Quantitative Results: Improvements in leg pain (>2 points in NRS), disability (>15 points in ODI for 92.9% of patients), and quality of life (≥12 points in EQ VAS for 82.6% of patients) are clinically significant, offering robust support for the device’s efficacy.

Weaknesses and Limitations Short Follow-Up Period: While the six-month follow-up provides early insights into the device’s safety and efficacy, recurrent disc herniations often occur beyond this timeframe. Longer-term data are essential to confirm durability and sustained benefits.

Small Sample Size: The study includes only 30 patients, limiting the generalizability of its findings. A larger cohort would enhance statistical power and the reliability of conclusions.

Lack of Control Group: The absence of a control group undergoing standard discectomy without HBS implantation makes it challenging to attribute observed benefits solely to the device. Randomized controlled trials (RCTs) are necessary to establish causation.

Subjective Outcome Measures: While NRS, ODI, and EQ-5D-5L are validated tools, they are subjective and may be influenced by patient expectations or placebo effects. Objective functional outcomes or imaging-based metrics could supplement these measures.

Potential Conflicts of Interest: The involvement of NEOS Surgery S.L. in providing the device introduces a potential bias. Transparency about funding and potential conflicts is crucial, though not explicitly addressed in the abstract.

Future Directions Extended Follow-Up: Studies with follow-ups of 2–5 years are needed to evaluate the long-term efficacy and safety of the HBS, particularly in preventing delayed reherniations and preserving disc height.

Larger, Controlled Trials: Conducting RCTs comparing HBS implantation to standard discectomy or other augmentation methods (e.g., annular closure devices) will provide more definitive evidence of its benefits.

Economic Analysis: A cost-effectiveness analysis of the HBS compared to traditional methods would be valuable, given the potential implications for widespread adoption in clinical practice.

Broader Patient Inclusion: Expanding the study to include patients with different types of disc herniations or annular defect sizes may clarify the broader applicability of the device.

Conclusion This study offers promising early evidence supporting the safety and efficacy of the HBS in preventing early recurrent lumbar disc herniation. Despite its limitations, the research sets a strong foundation for further investigation and highlights the potential of this novel device to address a significant clinical challenge. However, longer follow-ups, larger sample sizes, and randomized controlled comparisons are imperative to confirm these findings and establish the HBS as a standard of care in spinal surgery.

1)

Godino O, Fernandez-Carballal C, Català I, Moreno Á, Rimbau JM, Alvarez-Galovich L, Roldan H. A new hernia blocking system to prevent recurrent lumbar disc herniation: surgical technique, intraoperative findings and six-months post-operative outcomes. Eur Spine J. 2024 Dec 8. doi: 10.1007/s00586-024-08595-x. Epub ahead of print. PMID: 39648196.