Search Results (337)

Surgical site infections (SSIs) remain a significant complication in spine surgery, especially in instrumented procedures with long operative times. Although guidelines recommend cefazolin as the first-line agent due to its efficacy against Staphylococcus aureus, predictable pharmacokinetics, and safety, its real-world practice is highly variable, with inappropriate and prolonged regimens reported across Europe. Vancomycin is often used as the first choice of therapy empirically and without screening, exposing patients to risks such as delayed infusion, nephrotoxicity, and the emergence of vancomycin-resistant enterococci (VRE).This review assesses the present function of vancomycin in relation to cefazolin for spinal prophylaxis and examines wider trends in the misuse of surgical antibiotic prophylaxis, which were identified through PubMed and Scopus searches. Evidence from randomized and prospective studies consistently supports cefazolin as the preferred prophylactic agent in clean spinal surgery. Observational data suggest that adjunctive or topical vancomycin may reduce infection rates in selected high-risk or revision cases, though the results are inconsistent and frequently limited by retrospective designs and heterogeneous outcome reporting. Importantly, the most rigorous randomized controlled trial found no benefit of intrawound vancomycin over the placebo. A small number of available investigations in vancomycin use with major design limitations have resulted in no significant VRE emergency. Unexpectedly, widespread use of vancomycin was followed by a notable transition toward Gram-negative and opportunistic organisms. In summary, vancomycin may only be considered in patients with documented MRSA colonization, β-lactam allergy, or selected revision procedures, but its widespread empirical use as a first-choice therapy is not supported. Full article

Background/Objectives: The spinal cord is a critical component of the central nervous system that transmits neural signals between the brain and the body’s peripheral regions through its nerve roots. Despite being partially protected by the vertebral column, the spinal cord remains highly vulnerable to trauma, tumors, infections, and degenerative or inflammatory disorders. These conditions can disrupt neural conduction, resulting in severe functional impairments, such as paralysis, motor deficits, and sensory loss. Therefore, accurate and comprehensive spinal cord segmentation is essential for characterizing its structural features and evaluating neural integrity. Methods: In this study, we propose a fully automated method for segmentation of the cervical spinal cord in sagittal magnetic resonance (MR) images. This method facilitates rapid clinical evaluation and supports early diagnosis. Our approach uses a Swin-Unet architecture, which integrates vision transformer blocks into the U-Net framework. This enables the model to capture both local anatomical details and global contextual information. This design improves the delineation of the thin, curved, low-contrast cervical cord, resulting in more precise and robust segmentation. Results: In experimental studies, the proposed Swin-Unet model (SWU1), which uses transformer blocks in the encoder layer, achieved Dice Similarity Coefficient (DSC) and Hausdorff Distance 95 (HD95) scores of 0.9526 and 1.0707 mm, respectively, for cervical spinal cord segmentation. These results confirm that the model can consistently deliver precise, pixel-level delineations that are structurally accurate, which supports its reliability for clinical assessment. Conclusions: The attention-enhanced Swin-Unet architecture demonstrated high accuracy in segmenting thin and complex anatomical structures, such as the cervical spinal cord. Its ability to generalize with limited data highlights its potential for integration into clinical workflows to support diagnosis, monitoring, and treatment planning. Full article

Background: Ventriculoperitoneal shunting (VPS) is the mainstay of treatment for most forms of hydrocephalus; VPS infection (VPSI) is a leading cause of shunt-related morbidity and mortality. A meta-analysis of the existing literature on risk factors for VPSI is currently lacking. Herein, the authors performed a systematic review and meta-analysis to evaluate the role of different clinical factors in the development of VPSI. Methods: A systematic search in the PubMed, Scopus, and Cochrane databases was performed to identify studies comparing patients developing VPSI to controls. The following data were extracted where available: number of patients who developed VPSI vs. number of patients with a regular course, demographics (gender, age at VPS insertion, age > 18 years), average length of hospital stay before shunt implant (days), aetiology of hydrocephalus (tumour-associated hydrocephalus; post-haemorrhagic hydrocephalus; congenital hydrocephalus; spinal dysraphism-associated hydrocephalus; post-infectious hydrocephalus; post-traumatic hydrocephalus; post-craniotomy hydrocephalus), and hydrocephalus type (obstructive hydrocephalus, communicating hydrocephalus, normal-pressure hydrocephalus—NPH). Results: Five studies including 2333 patients (225 with VPS infection) were analysed. Tumour-related hydrocephalus was linked to a lower infection risk (OR 0.418; p < 0.001), while congenital hydrocephalus (OR 2.502; p < 0.001) and spinal dysraphism (OR 2.359; p < 0.001) increased the risk. Conclusions: VPSI represents a serious complication after shunt surgery. Our meta-analysis identifies three key factors influencing the risk of VPSI. VPS-centred, large multicentre prospective studies are needed to possibly confirm the role of the factors we identified and to identify additional ones, enabling earlier detection of VPSI and allowing for better patient care. Full article

We reviewed vancomycin-resistant Enterococcus (VRE) colonisation of inpatients of a spinal cord injury centre. The centre consists of one single occupancy en suite room and ten multi-occupancy rooms where two to six patients stay in a cubicle. These patients share bathroom and toilet facilities. Active screening for VRE is performed by taking rectal swabs on admission of patients to the spinal unit. The patients, who are colonised with VRE, are not isolated due to constraints in resources. During a twelve-month period (April 2024 to April 2025), 33 patients tested positive for VRE. In April 2025, 17 of 40 in-patients tested positive for VRE. During the last six 12-month periods from 2019, the number of patients testing positive for VRE has shown an upward trend from 18 during 2019–2020 to 33 during 2024–2025. No patient developed systemic infection with VRE (blood stream infection, endocarditis, meningitis, intra-abdominal sepsis, infection of a spinal implant or baclofen pump) during the study period. Twelve patients underwent implantation of a baclofen pump during 2024–2025. No patient developed VRE infection from the implant. We believe that non-isolation of patients colonised with VRE may be a pragmatic approach in a resource-poor healthcare facility. It is possible that non-isolation could have contributed to an increase in the number of patients who became colonised with VRE. Attention should be paid to infection prevention measures including hand washing and environmental cleaning to prevent the spread of VRE colonisation of inpatients and VRE infection of at-risk patients, e.g., immune-compromised individuals. Full article

Background/Objectives: Rates of degenerative spinal pathology are increasing, driving interest in minimally invasive surgical (MIS) techniques that facilitate faster recovery. Full endoscopic lumbar discectomy (FELD) and biportal endoscopic lumbar discectomy (BELD) offer reduced tissue disruption, but comparative outcomes versus non-endoscopic MIS and optimal patient selection remain unclear. This systematic review examines pre-operative characteristics and post-operative outcomes of endoscopic lumbar microdiscectomy (ELMD) compared to MIS and open techniques. Methods: A PRISMA-guided search of PubMed, Embase, Scopus, and hand searches through 31 September 2024 identified studies on lumbar spinal surgery using endoscopic techniques, restricted to level 1a/b and 2a evidence. Articles were subgrouped by surgery type, with this analysis focusing on ELMD. Data extraction included risk-of-bias assessment, and meta-analysis was performed using multivariate mixed-effects regression. Pre-operative patient characteristics and post-operative outcomes for endoscopic lumbar microdiscectomy (ELMD) were directly compared to both open microdiscectomy and minimally invasive non-endoscopic microdiscectomy (MIS) techniques. Within the ELMD cohort, we further analyzed differences between full endoscopic (FELD) and biportal endoscopic (BELD) approaches, as well as between transforaminal and interlaminar access routes. Results: Of 6891 articles, 5469 unique titles/abstracts were screened, yielding 87 studies (3238 patients) for final synthesis. Compared to open microdiscectomy, ELMD patients were more often male, younger, of lower BMI, and had more comorbidities. They typically presented with shorter symptom duration and predominant radiculopathy. ELMD was performed most at L3–L4 and L4–L5. Post-operatively, ELMD patients had significantly lower VAS Leg Pain scores at 1 day and 1 year and reduced recurrence rates. ELMD was associated with lower recurrence rates and correspondingly lower revision surgery rates, with dural tears and wound infections trending lower compared to open surgery. Compared to non-endoscopic MIS, pre- and post-operative characteristics were similar. BELD patients more often had longer symptom duration, motor weakness, and hyporeflexia than FELD patients. Conclusions: ELMD patients demonstrate favorable pain relief and reduced recurrence versus open surgery, with outcomes comparable to MIS. These findings support ELMD as a less invasive alternative within the MIS spectrum. Full article

Introduction: Cervical disc disease is a common cause of disability worldwide. Two surgical options for refractory CDD are anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA). While ACDF is well established, CDA offers motion preservation and has shown promising outcomes. This study compared utilization trends, patient characteristics, and hospitalization outcomes of ACDF and CDA using a large national dataset. Methods: We analyzed patients in the Nationwide Inpatient Sample (2016–2019) undergoing ACDF or CDA, identified using ICD-10 codes. After exclusions, 97,999 patients were included. Propensity score matching yielded 11,415 pairs, enabling balanced comparisons of demographics, comorbidities, complications, length of stay (LOS), and hospital charges. Results: CDA utilization increased during the study period. Compared with ACDF, CDA patients were younger and more likely to have private insurance. Following matching, both groups were demographically similar. CDA was associated with a slightly shorter LOS (1.32 vs. 1.39 days) but significantly higher charges (USD 82,431 vs. USD 58,472). In terms of complications, dysphagia was more frequent after ACDF, whereas cervical spinal cord injury and urinary tract infections were slightly more common after CDA, though rare overall. Conclusions: CDA is increasingly adopted in younger, privately insured patients and demonstrates comparable safety with ACDF. Its advantages include motion preservation, shorter hospitalization, and lower dysphagia rates, though at the expense of higher costs. These findings support the selective use of CDA as a viable alternative to ACDF in appropriately chosen patients. Full article

Background: Rett syndrome (RS) is a rare neurodevelopmental disorder primarily affecting females, characterized by severe neurological impairment and complex comorbidities, including epilepsy, scoliosis, and respiratory dysfunction. Respiratory complications, such as recurrent infections and sleep-disordered breathing (SDB), are increasingly recognized as significant contributors to morbidity. This study aimed to evaluate the prevalence, severity, and management of major comorbidities—including epilepsy, scoliosis, respiratory infections, and SDB—in a pediatric cohort with genetically confirmed RS. Methods: We conducted a retrospective review of medical records from 23 female patients under 18 years of age with MECP2 mutations, referred to our tertiary care center from 2021 to 2025. Data on epilepsy, scoliosis, respiratory infections, and nutritional status were collected. The presence of SDB was assessed through overnight home polygraphy (oPG) and transcutaneous carbon dioxide monitoring in selected cases. Results: Epilepsy affected 65% of patients, all with good seizure control. Scoliosis was present in 52%, with two patients requiring spinal surgery. At least one episode of lower respiratory tract infection (LRTI) was presented in 39% of our girls. LRTIs positively correlated with the number of hospitalization and antibiotic treatment. Among patients undergoing oPG, 67% presented obstructive sleep apnea, with its severity positively correlating with the frequency of lower respiratory infections. Severe nocturnal hypercapnia was documented in three patients, leading to non-invasive or invasive ventilation. Conclusions: Our findings highlight the high prevalence of sleep-related respiratory disorders and their association with respiratory infections in children with RS. Systematic respiratory assessment, including sleep studies, and early implementation of airway clearance techniques and ventilatory support are crucial to improving clinical outcomes in this vulnerable population. Full article

Background and Objectives: Pyogenic spondylodiscitis (SD) is a severe spinal infection involving the intervertebral disc and adjacent vertebrae and is often associated with significant morbidity. Identifying the causative microorganism is crucial for targeted treatment; however, the microbiological yield from blood or tissue cultures varies widely due to factors such as prior antibiotic use and biopsy technique. In this study, we aimed to investigate the clinical, laboratory, and radiological predictors of microbiological yield, particularly from tissue biopsy specimens. Materials and Methods: This retrospective cohort study included adult patients diagnosed with pyogenic SD between January 2023 and July 2025 at a tertiary care hospital. Demographics, comorbidities, laboratory markers (CRP, ESR, ALP, albumin), radiological findings (abscess presence, anatomical location, claw sign), prior antibiotic use, and microbiological results were analyzed. Tissue specimens were obtained through either surgical sampling or needle biopsy. Univariable and multivariable logistic regression were performed to determine the predictors of positive tissue cultures. Results: Of the 159 patients screened, 55 met our inclusion criteria. The mean age was 63.9 ± 13.5 years, 80% had lumbar involvement, and 58.2% had abscesses, primarily paravertebral or psoas in location. Microorganisms were isolated in 65.5% of the cases, with Staphylococcus aureus being the most common (41.7%). The blood culture positivity was 55.5%, while tissue culture positivity was 40.4%. Logistic regression revealed that lower albumin (p = 0.046) and higher ALP levels (p = 0.045) were independent predictors of a positive microbial yield from tissue biopsies. Conclusions: Serum albumin and ALP levels may aid clinical decision-making regarding invasive sampling in SD. When blood cultures are negative and albumin is low while ALP is elevated, clinicians should consider prioritizing tissue biopsy. These findings may help optimize diagnostic strategies and should be validated in larger, prospective studies. Full article

Percutaneous vertebroplasty (PVP) has emerged as a key intervention for painful vertebral compression fractures in osteoporotic and metastatic disease, but its safety profile warrants comprehensive evaluation. We conducted a PRISMA-compliant systematic review of studies published between 2009 and 2024, identifying 15 clinical studies (n ≈ 8500 patients) that reported PVP-related complications in adults with osteoporotic or neoplastic fractures. Data extraction focused on complication incidence, presentation, imaging findings, risk factors, and management strategies. Cement leakage was the most frequently detected event (20–70% of levels, higher in neo-plastic lesions), yet symptomatic neural or vascular sequelae occurred in <1%. Pulmonary cement embolism appeared on imaging in 2–26% of cases but was clinically evident in ≤0.5%, with conservative management or brief anticoagulation sufficing for most patients. New vertebral fractures developed in 8–20% of osteoporotic and up to 30% of metastatic cohorts, paralleling underlying bone fragility rather than PVP itself. Postprocedural infection (0.2–0.5%) and neurologic injury (<0.5%) were uncommon but required prompt surgical and antibiotic interventions. Overall, PVP’s benefits—rapid pain relief and mechanical stabilization—outweigh its risks when performed with meticulous technique, vigilant imaging, and multidisciplinary follow-up, confirming its favorable safety profile in both osteoporosis and spinal malignancy. Full article

Meningococcal meningitis is a deadly acute bacterial infection caused by the Neisseria meningitidis bacterium that affects the membrane covering the brain and spinal cord. The World Health Organization launched the “Defeating bacterial meningitis by 2030” initiative in 2018, which relies on recent discoveries of cheap and effective vaccines. Here, we consider one important factor—human behavior—which is often neglected by immunization campaigns. We constructed a game-theoretic model of meningitis in the meningitis belt, where individuals make selfish rational decisions whether to vaccinate based on the assumed costs and the vaccination decisions of the entire population. We identified conditions when individuals should vaccinate, and we found the optimal (equilibrium) population vaccination rate. We conclude that voluntary compliance significantly reduces the endemic levels of meningitis if the cost of vaccination relative to the cost of the disease is sufficiently low, but it does not eliminate the disease. We also performed uncertainty and sensitivity analysis on our model. Full article

Background: Serum markers are commonly used to diagnose bone and joint infections; however, their accuracy for diagnosing pyogenic spondylitis remains unproven. This study aimed to validate the diagnostic accuracy of inflammatory, nutritional, and immunological serum markers for spinal infections and identify the most effective combinations. Methods: The retrospective cohort study analyzed 656 patients who visited the hospital for spinal diseases between 1 January 2004 and 31 March 2021; a total of 76 were diagnosed with pyogenic spondylitis. Blood samples were analyzed for serum albumin (Alb), total protein (TP), globulin (Glb), C-reactive protein (CRP), platelet count, white blood cell count, neutrophil count, lymphocyte count, and monocyte count. Combination markers, including albumin–globulin ratio (AGR), CRP–albumin ratio (CAR), CRP–AGR (CAGR), neutrophil–lymphocyte ratio (NLR), and platelet–lymphocyte ratio (PLR), were also evaluated. Receiver operating characteristic curves were used to determine each marker’s diagnostic performance. Furthermore, multivariate analysis was performed to examine the odds ratios. Results: Patients with pyogenic spondylitis showed significantly different levels in Alb (p < 0.0001), Glb (p < 0.0001), CRP (p < 0.0001), platelet count (p < 0.0001), WBC count (p < 0.0006), neutrophil count (p = 0.0019), lymphocyte count (p = 0.0085), AGR (p < 0.0001), CAR (p < 0.0001), CAGR (p < 0.0001), NLR (p < 0.0001), and PLR (p < 0.0001). CRP (AUC = 0.80) showed good diagnostic accuracy, while combination markers CAR (AUC = 0.82) and CAGR (AUC = 0.83) had the highest areas under the curve (AUC). Multivariate analysis indicated that decreased age and the presence of comorbidities (including chronic kidney disease, chronic liver disease, malignancy, or diabetes), were independent predictors of early pyogenic spondylitis (OR_age = 0.93, OR_comorbidities = 16.98, p_age = 0.0005, and p_comorbidities = 0.0001). In patients with low-inflammatory pyogenic spondylitis, significant differences were observed in TP (p = 0.0293), Glb (p = 0.0012), CRP (p = 0.0023), platelet count (p = 0.0108), AGR (p = 0.0044), CAR (p = 0.0006), CAGR (p = 0.0004), PLR (p = 0.0192), and NLR (p = 0.0027), with CAGR showing the highest AUC (AUC = 0.70) among them. Conclusions: Serum combination markers (AGR, CAGR, CAR, PLR, and NLR) showed diagnostic value for pyogenic spondylitis, with CAGR achieving the highest accuracy. In low-inflammatory pyogenic spondylitis patients (CRP ≤ 1.0 mg/dL), these markers may aid diagnosis. Full article

Infections following spinal surgery can result in potentially devastating complications. An accurate microbiological diagnosis is crucial for proper treatment. Sonication is a diagnostic method that can be beneficial in patients with acute or low-grade infections. This study aimed to assess the sensitivity and effectiveness of sonication as a method for diagnosing spinal implant infections in cases of both suspected and unsuspected infections during spinal surgical revision. We conducted a retrospective observational study that included all patients who underwent revision spinal surgery between March 2011 and October 2022. We collected the implants and surrounding tissues from these patients for microbiological analysis. The implant sonication was performed according to a previously published protocol. Patients were categorised into those undergoing surgical revision for suspected spinal implant infection (SSII) and those for non-suspected spinal implant infection (NSSII). We collected comprehensive patient data, including demographics, risk factors, Charlson Comorbidity Index (CCI), surgical details, microbiological findings, antibiotic regimens, and clinical outcomes. Sensitivity and specificity analyses were conducted on both sonicated and non-sonicated samples. A total of 158 patients met the inclusion criteria; 51 of them were diagnosed with infection during surgery revision. Patients with SSII had higher CCIs than those with NSSII. The sensitivity was significantly higher in sonicated samples (68.6%; 95% CI: 55.9–81.4%) than in non-sonicated samples (42%; 95% CI: 28.3–55.7%). The specificities were similar, with sonicated samples at 93.5% (95% CI: 88.8–98.1%) and non-sonicated samples at 99.05% (95% CI: 97.2–100.9%). Combining both methods resulted in sensitivity and specificity rates of 76% (95% CI: 64.2–87.8%) and 93.3% (95% CI: 88.2–98.1%), respectively. Methicillin-susceptible Staphylococcus aureus (MSSA) was common in SSII, whereas Cutibacterium acnes and coagulase-negative Staphylococcus (CNS) were predominant in NSSII. This study supports the routine use of implant sonication as a valuable supplementary method for peri-implant tissue cultures, especially for identifying low-grade spinal implant infections. Full article

Purpose: Thoracolumbar burst fractures represent a significant proportion of spinal injuries, with management strategies remaining a subject of debate. While four-screw (4S) short-segment posterior fixation is commonly used, recent biomechanical studies suggest that adding pedicle screws at the fractured level (six-screw, 6S, construct) may improve stability and clinical outcomes. However, the clinical relevance of these findings remains uncertain. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Three databases (Scopus, PubMed/MEDLINE, Cochrane Library) were searched for studies comparing 4S and 6S constructs in thoracolumbar fractures. Inclusion criteria encompassed comparative clinical studies reporting perioperative, functional, and radiological outcomes. Data were extracted and analyzed using Review Manager 5.4.1, applying fixed- or random-effects models based on heterogeneity. Results: Twenty-two studies involving 1595 patients were included. The 6S group showed significantly improved postoperative pain scores (VAS), better short- and long-term sagittal alignment, and a lower implant failure rate. However, this technique was associated with longer operative times, increased intraoperative blood loss, and extended hospital stays. No significant differences in long-term functional disability (ODI) or infection rates were found. Conclusions: The addition of intermediate screws improves radiological outcomes and reduces implant failure but increases surgical burden. Further high-quality studies focusing on patient-reported outcomes and specific fracture subtypes are needed to refine clinical indications. Full article

Background: Neurogenic bladder (NB) in children may lead to recurrent urinary tract infections (UTIs), renal deterioration, and a reduced quality of life. Clean intermittent catheterization (CIC) is the standard of care, but in some patients, CIC may be unfeasible due to anatomical, sensory, or compliance issues. Button cystostomy (BC) has emerged as a minimally invasive, bladder-preserving alternative. This study aimed to assess the feasibility, safety, and outcomes in the long-term of BC in pediatric NB patients. Methods: Retrospective analysis was conducted on children with NB who underwent endoscopic BC placement between January 2020 and December 2024 in a tertiary pediatric center. Demographic data, operative time, complications, and follow-up outcomes were collected. All procedures used an endoscopic approach with cystoscopic guidance for safe device placement. Results: Thirty-three patients (25 males; median age 7.96 years) underwent BC placement. Most had spinal dysraphism (63.6%). The mean operative time was 48.5 ± 6 min. During a mean follow-up of 2.1 ± 1.4 years, five patients (15.2%) had febrile UTIs and two had minor leakage. No major complications occurred. Four buttons were removed due to clinical improvement (N = 1), the fashioning of a continent derivation (N = 1) and implantation of a sacral neuromodulator (N = 2); two patients accepted CIC. Satisfaction was reported by 93.9% of families. Conclusions: BC is an effective, minimally invasive alternative for urinary drainage in children with NB, even when compared to continent diversion techniques such as the Mitrofanoff, due to its lower invasiveness, greater feasibility, and lower complication rate. Broader adoption may be warranted, but prospective studies are needed to confirm long-term outcomes. Full article

Background/Objectives: Limited robust data support the use of antibiotic combinations in the treatment of orthopedic infections. However, in certain situations, the combination of antibiotics seems to be beneficial. This review aims to outline the circumstances under which a combination of antibiotics may be utilized in the treatment of orthopedic infections. Methods: We reviewed the existing guidelines on orthopedic infections and focused on situations where antibiotic combinations are recommended or proposed optionally. We chose vitro and animal studies that provide evidence for the effectiveness of several widely recommended combinations. Results: The combinations serve multiple purposes: they provide empirical coverage while awaiting microbiological results, offer targeted treatment for difficult-to-treat infections, and facilitate oral treatment primarily for staphylococcal infections. The objectives include enhancing bacterial coverage against Gram-positive and Gram-negative bacteria, achieving synergistic effects with bactericidal agents, and reducing the risk of antibiotic resistance. The review outlines specific combinations for fracture-related infections, periprosthetic joint infections, spinal infections, and anterior cruciate ligament reconstruction infections, emphasizing the importance of tailoring antibiotic choices based on local epidemiology and patient history. The review also addresses potential drawbacks of combination therapy, such as toxicity, higher costs, and drug interactions, underscoring the complexity of managing orthopedic infections effectively. Conclusions: According to the guidelines, several different proposals are made, depending in part on the countries’ epidemiology. In a well-defined situation, various authors propose either monotherapy or a combination of antibiotics. When a combination is suggested, the choice of antibiotics is based on the expected effect: broadening the spectrum, enhancing bactericidal activity, achieving a synergistic effect, or reinforcing biofilm activity to optimize the treatment. Full article