Answer to Case of the Month #3. Pyogenic discitis. Staphylococcal discitis complicated by bilateral psoas abscesses.
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Abscess↗
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Discitis associated with pregnancy and spinal anesthesia.
UNLABELLED: Discitis (inflammation of the intervertebral disk) most commonly develops as a rare complication of bacterial infection or chemical or mechanical irritation during spine surgery (1) with a postoperative incidence of 1%-2.8% (2). It is also a complication of discography-the intradiscal injection of saline or contrast material (3). The incidence of postdiscography discitis is 1%-4% (3); no cases have been reported when prophylactic antibiotics have been used, supporting the theory of bacterial contamination (3). Although it is controversial whether discitis can be caused by an aseptic or infectious process, recent data suggest that persistent discitis is almost always bacterial (4). Honan et al. (5) reported 16 cases of spontaneous discitis and reviewed another 52 patients from the literature. In their series, patients tended to have one or more comorbid conditions, such as diabetes, vertebral fracture, or a preexisting spine injury. Spontaneous discitis has also been associated with advanced age, IV drug abuse, IV access contamination, urinary tract infection, and immunocompromised states (5,6). No cases of infectious discitis associated with pregnancy and spinal anesthesia have been reported in the English literature. Discitis presents as spasmodic pain in the back that may be referred to the hips or groin (7). The pain may radiate to the lower extremities. The erythrocyte sedimentation rate is usually increased. Radiological changes in discitis include narrowing of the intervertebral disk space, vertebral sclerosis, and erosion of the end plates. The best diagnostic measure may be magnetic resonance imaging (MRI) or a combination of bone and gallium scanning (2). The mainstay for discitis treatment is pain control and antibiotics; surgical intervention is usually not required. Complications of discitis include intervertebral fusion, epidural abscess, and paralysis. IMPLICATIONS: This is a case report of a disk infection (discitis) caused by the bacteria, Streptococcus bovis after spinal anesthesia for cesarean delivery. S. bovis rarely causes discitis, and spinal anesthesia for labor and delivery has not been reported as a cause of discitis.
Adult↗
Aseptic discitis in patients with ankylosing spondylitis: a retrospective study of 14 cases.
OBJECTIVES: To determine whether patients with ankylosing spondylitis (AS) and discitis exhibit specific characteristics as compared to patients who have AS without discitis. METHODS: We retrospectively collected clinical, laboratory, and imaging data from the charts of 79 patients with AS admitted to a rheumatology department. RESULTS: Of the 79 patients, 14 (18%) had discitis that was not due to infection or trauma. Mean age at the diagnosis of AS was 40 years and mean duration of AS at admission was 10 years, with no difference between the two groups. In three patients, discitis was the inaugural manifestation of AS. Two patients had discitis at two levels. The lumbar and thoracolumbar segments were the most common sites of discitis. Symptoms of discitis were present in 10 of the 14 patients. Stage III sacroiliitis was significantly more common in the patients with discitis. None of the patients experienced neurological compromise. CONCLUSION: The frequency of aseptic discitis in patients with AS is probably overestimated as a result of inclusion and exclusion biases. Discitis usually occurs at an advanced stage of AS under the form of an erosive condition related to both mechanical factors and osteoporosis. Inaugural or early discitis can occur, however, as a result of the inflammatory process.
Adolescent↗
Discitis and vertebral osteomyelitis in children: an 18-year review.
BACKGROUND: Discitis and vertebral osteomyelitis are uncommon entities, and diagnosis often is confounded by their similar clinical presentation, because characteristic radiographic findings are not evident until late in the course of illness. OBJECTIVE: To compare the age distribution, clinical manifestations, and radiographic findings, especially magnetic resonance imaging (MRI), in children with discitis or vertebral osteomyelitis. METHODS: A retrospective review of 57 children with a discharge diagnosis of discitis or vertebral osteomyelitis hospitalized from January 1980 through December 1998. RESULTS: Fifty patients met inclusion criteria: 36 with discitis and 14 with vertebral osteomyelitis. The mean age at presentation was younger for children with discitis than for those with vertebral osteomyelitis (2.8 vs 7.5 years of age) and the duration of symptoms longer for children with vertebral osteomyelitis than for those with discitis (33 vs 22 days). The initial symptom for both groups of children was refusal to walk, limp, or back pain, but children with osteomyelitis more often were febrile (79% vs 28%) and ill-appearing than those with discitis. Thirty-three patients with discitis had radiographs of the spine; 25 (76%) had abnormalities that were diagnostic. Ten discitis patients had MRI; 9 (90%) had abnormalities consistent with this diagnosis. Thirteen children with vertebral osteomyelitis had radiographs of the spine, but in only 7 (54%) were these abnormal. However, 11 had MRIs, and in each the diagnosis of vertebral osteomyelitis was established. CONCLUSION: This comparative study suggests that age and clinical presentation distinguish most patients with discitis from those with vertebral osteomyelitis. Although radiographs of the spine usually are sufficient to establish the diagnosis of discitis, MRI is the diagnostic study of choice for pediatric patients with suspected vertebral osteomyelitis.
Adolescent↗
Postoperative discitis: outcome and late magnetic resonance image evaluation of ten patients.
BACKGROUND AND AIMS: MRI has proven to be the most effective method for demonstrating suspected postoperative discitis. The prognosis of discitis varies markedly in different series. The purpose of this study was to analyze the clinical outcome and late MRI findings of the patients with postoperative discitis. MATERIAL AND METHODS: The medical records of ten patients with discitis and of ten patients without infectious findings following lumbar discectomy in 1993 to 1995 were reviewed. A clinical follow-up investigation with a detailed questionnaire and MRI was performed. Without knowledge of the clinical history, a radiologist selected the cases of discitis based on evaluation of the MRI pictures, and thereafter after a combined analysis of preoperative CT scans and of the MRI pictures. RESULTS: The follow-up MRI demonstrated characteristic findings in every discitis case. However, similar changes were seen in four cases of the control group. The discitis group had more symptoms, a longer sick leave and less return to previous occupation than the control group. CONCLUSION: As a late examination, MRI is insufficient in itself for diagnosis of earlier discitis. Postoperative discitis lengthens the sick leave markedly. Patients with postoperative discitis are rarely capable to return to a physically strenuous work. Every effort, including antibiotic prophylaxis, should be undertaken to reduce the risk of this serious complication.
Adult↗
Spontaneous infectious discitis in adults.
PURPOSE: In adults, discitis most frequently follows spinal surgery. We report 16 adult patients with spontaneously occurring infectious discitis and compare them with an additional 52 patients abstracted from the literature. Infecting organisms, predisposing factors, imaging modalities, and response to therapy are described. PATIENTS AND METHODS: The medical records of adult patients treated for infectious discitis of a community hospital during the past 10 years were reviewed. Postoperative spine patients and patients with primary osteomyelitis were excluded. Sixteen patients were identified with spontaneous primary infection of the disc space. The particulars of comorbid conditions, infection organisms, site of culture, and response to antibiotic therapy were noted and compared to 52 additional cases of spontaneous discitis reported in the literature since 1980. RESULTS: A wide variety of infecting organisms was identified as causing spontaneous discitis, in contrast to previous reports of both postoperative discitis and spontaneous discitis. Nine of 10 patients with positive disc cultures had negative blood cultures. Appropriate antibiotics were curative in all patients but 1, regardless of the duration of symptoms. Nuclear imaging, computed tomography, and magnetic resonance imaging were all useful, although the last appears to be the most sensitive and specific imaging modality for detecting discitis. CONCLUSIONS: Spontaneous infectious discitis is an uncommon cause of low back pain in adults. Nevertheless, it should be considered in any patient with acute or subacute pain. Elevated acute-phase reactants with appropriate imaging modality suggest the diagnosis. given the wide variety of infecting organisms identified, culture of blood and/or disc for the specific causative organism is critical to successful treatment outcome.
Adolescent↗
Spontaneous corynebacterium discitis in a patient with chronic renal failure.
STUDY DESIGN: Case report describing spontaneous Corynebacterium diptheria discitis in a patient with chronic renal failure. OBJECTIVES: To describe this very rare form of discitis and the results of surgical and antibiotic therapy. SETTING: University Department of Neurosurgery, Turkey. CASE REPORT: A 55-year-old man with chronic renal failure presented with acute low-back pain. Lumbar magnetic resonance imaging (MRI) suggested discitis and osteomyelitis at the L5-S1 level. The L5-S1 disc was operated upon and the discectomy material was sent for pathological and microbiological analysis. RESULTS: Pathological examination revealed infection and bacterial culture grew C. diptheria. The patient was prescribed combination antibiotic therapy with vancomycin, a third-generation cephalosporin, and rifampicin. Clinical status improved after 8 weeks of therapy. Lumbar MRI revealed remission of the discitis and osteomyelitis after 10 months of follow-up. CONCLUSION: Chronic renal failure patients with low-back pain should be investigated for spinal infection. These individuals are prone to low-grade infection in the form of discitis or osteomyelitis. Corynebacterium subspecies rarely cause spontaneous discitis. This case is interesting because of the unusual causal organism and the occurrence of discitis in the setting of chronic renal failure.
Anti-Bacterial Agents↗
Septic and aseptic post-operative discitis in the lumbar spine--evaluation by MR imaging.
PURPOSE: The aim of this study was to determine whether it was possible to differentiate septic from aseptic post-operative discitis in the lumbar spine by means of MR imaging. MATERIAL AND METHODS: The study was a retrospective evaluation of 12 patients with prior lumbar discectomy and suspected post-operative discitis displaying low-back pain and typical MR findings. Six patients had elevated serum C-reactive protein (CRP) (septic) and 6 had normal CRP (aseptic). We used MR imaging to assess the distribution and degree of changes in the disc, in adjacent bone marrow, and in surrounding soft tissue. RESULTS: Of the 6 patients with increased CRP levels, 3 had extensive MR changes typical of septic post-operative discitis: 1 found soon after surgery; 2 found later. The other 3 patients with septic discitis, who were examined in the early post-operative period, showed MR changes similar to those in the 6 patients with aseptic discitis. CONCLUSION: Suspicion of septic post-operative discitis should be confirmed by MR imaging, serum CRP, and disc puncture. MR imaging is not reliable as the sole method for distinguishing septic from aseptic discitis in the early post-operative stage.
Adult↗
Pitfalls of computed tomography in diagnosis of discitis.
Sixteen patients with discitis from January 1980 through December 1983 underwent 18 CT scans for initial evaluation. In six scans the study produced a false negative result (sensitivity 63%, 11/16). In three of these six the scan was performed at the wrong disc level, and in three the error was interpretive. During the same time period 6 patients had a CT diagnosis of discitis which proved incorrect (positive predictive value 63%), three of which had fractures, two had normal post discectomy changes, and one had a neuropathic arthropathy. These studies were reviewed in a blinded fashion along with 30 CT scans of post operative patients without clinical or laboratory evidence of discitis. The CT findings in the discitis patients were: (a) anterior paravertebral soft tissue swelling with obliteration of paravertebral fat planes, (b) fragmentation or erosions of vertebral end plates, and (c) paravertebral fluid collection (abscess). Both (a) and (b) were seen in 13/15 patients, (a) alone in 1/15, (b) alone in 1/15, and all three (a, b, c) in 2/15. The CT scan is diagnostic of discitis in those with all three findings. In those patients with only (a) or both (a) and (b), the CT can be suggestive of discitis in the proper clinical setting when correlated with plain film findings: however, these CT findings are also observed in other conditions. Involvement of the spinal canal by inflammatory mass was seen in 6/16 patients with discitis. Low attenuation (hypodensity) of the affected disc was not observed.
Adolescent↗
Suspected disk space infection with negative microbiological tests-report of eight cases and comparison with documented pyogenic discitis.
UNLABELLED: Few data are available on patients with suspected noniatrogenic pyogenic discitis but negative microbiological tests. OBJECTIVES: To compare the features, treatment, and outcomes in patients with suspected versus microbiologically documented noniatrogenic pyogenic discitis. PATIENTS: A retrospective chart review identified eight patients with suspected noniatrogenic pyogenic discitis managed at our institution over a 15-year period. Eighteen age- and sex-matched patients with microbiologically documented noniatrogenic pyogenic discitis managed at our institution during the same period served as controls. RESULTS: The eight cases had a longer time to diagnosis, a greater risk of abscess formation or epidural infection, and a smaller number of cutaneous portals of entry, as compared to the controls. None of the cases had evidence of endocarditis or diabetes mellitus. Infection at another site preceded the discitis in half the cases. Empirical treatment with two antimicrobials (usually a fluoroquinolone with a beta-lactam or fosfomycin) ensured a full recovery in all eight cases, with no relapses or long-term recurrences, whereas relapses occurred in three of the 18 controls treated with antibiotics selected by antibiotic susceptibility testing. CONCLUSION: Noniatrogenic pyogenic discitis with negative microbiological studies is associated with distinctive clinical features consistent with smoldering infection. The outcome is favorable under empirical two-drug antimicrobial therapy, usually including a fluoroquinolone given by the intravenous route.
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A case ascertainment study of septic discitis: clinical, microbiological and radiological features.
We studied the spectrum of septic discitis presenting to two busy district general hospitals over 2.5 years (November 1996 to April 1999), surveying the case notes of all patients attending Royal Bournemouth and Poole Hospitals with probable septic discitis on magnetic resonance imaging (MRI). Twenty-two cases of septic discitis were identified, suggesting an annual incidence of 2/100 000/year. Seventy-three percent of patients were aged > or =65 years. In 91% of patients, back pain was the presenting symptom, with neurological signs evident in 45% of patients. Fever >37.5 degrees C was present in 68% of patients, and a marked elevation of erythrocyte sedimentation rate (ESR) in 91%. Diagnosis was originally by MRI in 86% of patients, with plain radiographs not diagnostic of discitis in the early stages of the infection. Staphylococcus aureus was the commonest pathogen (41%), but in 18% of patients, no organism was identified. The major predisposing factors to septic discitis were invasive procedures (41%), underlying cancer (25%) and diabetes (18%). Pre-existing degenerative spinal disease was found in 50% of patients. Four patients whose causative organism was not isolated had a poorer outcome: one death and three with increased morbidity. Our estimated incidence rate (2/100 000/year) is higher than that in previous studies and may be due to a higher detection rate with MRI and/or a genuine increase in the number of cases. Septic discitis should be considered in any patient who has severe localized pain at any spinal level, especially if accompanied by fever and elevated ESR, or in the immunosuppressed.
Adult↗
Distant skip level discitis and vertebral osteomyelitis after caudal epidural injection: a case report of a rare complication of epidural injections.
STUDY DESIGN: A case report of distant discitis and vertebral osteomyelitis involving skip levels after caudal epidural steroid injection. OBJECTIVES: To report and investigate the occurrence of distant infective discitis and vertebral osteomyelitis involving skip levels after epidural injection. SUMMARY OF THE BACKGROUND DATA: Distant discitis and vertebral osteomyelitis is a serious but rare complication after epidural injection. A case involving skip levels and without the occurrence of epidural abscess formation has apparently not been previously reported in the literature. METHODS: An elderly woman presenting with clinical, radiologic, and magnetic resonance imaging evidence of spinal canal stenosis involving L3/4 and L4/5 levels and degenerative spondylolisthesis of the L4/5 level was given an epidural injection of steroids and lignocaine via the caudal route. A month later, she presented with worsened low back pain, elevated serum acute phase reactants, and plain radiographic evidence of L4/5 infective discitis. Magnetic resonance imaging and microbiologic examination of computed tomographically guided biopsy specimens confirmed infective discitis involving L2/3 and L4/5 intervertebral levels, together with adjacent vertebral osteomyelitis. RESULTS: The patient was successfully treated with antibiotics targeted at Pseudomonas aeruginosa, which was isolated in the culture of the biopsy specimens. Follow-up improvements in the clinical condition, serum acute phase reactants levels, radiographs, and magnetic resonance imaging were noted. CONCLUSIONS: Distant discitis and vertebral osteomyelitis involving skip levels and without the occurrence of epidural abscess formation is a serious but rare complication after epidural injection.
Aged↗
Prophylactic cephazolin to prevent discitis in an ovine model.
STUDY DESIGN: An ovine model of discitis was used to determine the efficacy of the antibiotic cephazolin for prophylactic use in spinal surgery. OBJECTIVES: To determine in juvenile and adult sheep spines if 2-g cephazolin given at intervals over a 4-hour period would prevent iatrogenic discitis, and determine the concentration of cephazolin in nucleus and anulus tissue after administration of a bolus dose. SUMMARY OF BACKGROUND DATA: It is standard practice at our institutions to give patients undergoing spinal surgery a single prophylactic (1-2 g) dose of cephazolin with a second dose for prolonged (>4 hours) procedures. Although this regimen provides therapeutic serum levels, the levels of antibiotic in the intervertebral disc are significantly lower. Because cephazolin is a negatively charged molecule, it is thought to diffuse poorly into the disc, raising questions about its efficacy as a prophylactic antibiotic for spinal procedures. METHODS: There were 18 animals, including 9 lambs and 9 sheep, that received a single 2-g dose of cephazolin intravenously at 30-minute intervals over a 4-hour period. Two control animals (1 sheep and 1 lamb) did not receive antibiotic. All animals had diskograms at 2 previously incised lumbar levels and 2 nonincised levels using contrast that was deliberately contaminated with bacteria. Lateral spine radiographs were taken at postoperative intervals. After 12 weeks, all animals received another 2-g dose of cephazolin intravenously at intervals before the spines were removed for pathologic and biochemical analysis. RESULTS: Discitis was detected in all control animals. Of those animals given cephazolin, discitis developed in 1 sheep and 4 lambs. Discitis did not develop in any of the sheep that received cephazolin 30 minutes before inoculation. Cephazolin was detected throughout the disc but was more concentrated in the anulus fibrosus. Disc levels of cephazolin peaked at 15 minutes, at which time serum levels were up to 50 times higher. Cephazolin levels in nonoperated and incised discs were not significantly different. CONCLUSIONS: A single prophylactic 2-g dose of cephazolin administered anytime over a 4-hour period prevented discitis in almost all animals but was not as effective in lambs. Although lambs have a higher vascular supply to deliver antibiotics to the disc, it is likely that some other physiologic factor may be responsible for the increased infection rate. This study supports that timing of antibiotic prophylaxis is critical to prevent iatrogenic disc infection.
Animals↗
Bacterial endocarditis revealed by infectious discitis.
A study of 30 patients admitted for infectious discitis identified four cases with concomitant bacterial endocarditis. All four patients were male and had concomitant streptococcal septicemia. Two patients had known aortic valve disease. The vertebral infection was located to the thoracic or lumbar spine. Ultrasonography disclosed aortic lesions in all four patients and mitral lesions in two. Management consisted of intravenous antimicrobial therapy for four weeks followed by a three-month course of oral antimicrobial therapy. The outcome of the discitis was favorable within the usual period of time. However, the endocardial lesions continued to progress, and three patients rapidly required valve replacement. Analysis of available data in the 30 patients with discitis showed that half the patients with streptococcal discitis also had bacterial endocarditis and that the latter condition developed in all the patients with streptococcal discitis and a history of valve disease. A number of risk factors were identified. An echocardiogram should be done routinely in patients with infectious discitis and risk factors for bacterial endocarditis.
Adult↗
Discitis after discography.
Infection after intradiscal injections has been recognised as a distinct entity, but discitis after discography has often been attributed to an aseptic process or a chemical reaction to the contrast material. We examined the hypothesis that discitis after discography is always due to infection, and report a clinical review and an experimental study. Part I. We reviewed the case records and radiographs of 432 patients who had undergone lumbar discography. When an 18-gauge needle without a stilette had been used, discitis was diagnosed in 2.7% of 222 patients but stiletted needles and a two-needle technique at each level reduced the incidence to 0.7%. Seven patients with discitis after discography had undergone anterior discectomy and fusion; in them the histopathological findings were of a chronic inflammatory response. Bacteria were isolated from the discs of three of the four patients who had open biopsy less than six weeks from the time of discography. These findings suggest that bacteria were initiators rather than promoters of the response. Part II. Multiple level lumbar discography was carried out in mature sheep, injecting contrast material with or without various concentrations of bacteria. Radiographs were taken and the discs and end-plates were examined histologically and cultured for bacteria at intervals after injection. None of the controls showed any evidence of discitis but all sheep injected with bacteria had typical radiological and histopathological changes by six weeks, though cultures were almost all negative. However, at one and two weeks after injection, but usually not after three weeks, bacteria could be isolated. We suggest that all cases of discitis after discography are initiated by infection, and that a very strict aseptic technique should be used for all injections into intervertebral discs.
Adolescent↗
Preventing and treating discitis: cephazolin penetration in ovine lumbar intervertebral disc.
Infection can occur after any spinal procedure that violates the disc and although it is not common, the potential consequences are serious. Treatment of discitis is not always successful and the key to management is prevention. Intradiscal prophylaxis with antibiotic is routinely used in spinal surgery, but there is a limited understanding of how well antibiotics can enter the avascular disc after intravenous injection. An in vivo ovine study to optimise prophylactic and parenteral treatment of discitis is described to assess the effectiveness of cephazolin in preventing and treating infection. The concentration of cephazolin was measured in disc tissue from normal and degenerate sheep discs to determine if cephazolin can enter the disc and if disc degeneration affects antibiotic uptake. Fourteen sheep were deliberately inoculated with bacteria to induce discitis. Eight sheep ("prophylaxis" group) were given either a 0, 1, 2 or 3 g dose of prophylactic cephazolin before inoculation while the remaining sheep ("treatment" group) were treated with cephazolin commencing 7 days after inoculation for 21 days at a dose of 50 mg/kg/day. Histopathology and radiography were used to assess the effect of the different treatments. Cephazolin was given 30 min prior to sacrifice and the intradiscal concentration was measured by biochemistry. In the "prophylaxis" group all doses of antibiotic provided some protection against infection, although it was not dose dependent. In the "treatment" group discitis was confirmed radiologically and histologically in all animals from 2 weeks onwards. Biochemical assay confirmed that antibiotic is distributed throughout the disc but was present in higher concentration in the anulus fibrosus than the nucleus pulposus. This study demonstrated that whilst the incidence of iatrogenic discitis can be reduced by antibiotic prophylaxis, it could not be abolished in all incidences with a broad-spectrum antibiotic such as cephazolin. Furthermore, antibiotics were ineffective at preventing endplate destruction once an intradiscal inoculum was established.
Animals↗
Management of postprocedural discitis.
BACKGROUND CONTEXT: Fortunately, the incidence of postprocedural discitis is relatively uncommon. The paucity of physical examination findings behooves the spine care practitioner to have a high index of suspicion in any patient presenting with increasing back pain after an invasive spinal procedure. The diagnosis can often be established in a timely fashion based on the history, physical examination, laboratory studies (erythrocyte sedimentation rate, C-reactive protein and blood cultures) and imaging studies (plain radiographs, magnetic resonance imaging, computed tomography and radionuclide scanning). PURPOSE: To review the English literature on the subject of postprocedural discitis. The incidence, pathophysiology, laboratory markers and imaging findings are discussed. Recommendations on treatment strategies are presented along with long-term clinical outcomes of this postprocedure complication. METHODS: A contemporary English literature search of MEDLINE and PubMed on the topic of postoperative discitis was performed. RESULTS: The incidence of postprocedural discitis is approximately 0.2%. The most common etiologic agent is Staphylococcus aureus. The C-reactive protein is the most sensitive clinical laboratory marker to assess the presence of infection and effectiveness of treatment response. Magnetic resonance imaging is the imaging modality of choice in the diagnosis of spinal infection. The majority of patients are managed adequately with organism-specific antibiotics and spinal immobilization with good long-term outcomes. Operative intervention (open biopsy followed by antibiotic treatment and spinal immobilization or debridement and reconstruction) in patients who fail to respond to nonoperative treatment or in the presence of neurologic worsening has been demonstrated. CONCLUSION: Postprocedural discitis is a rare complication after any invasive spinal procedure. It is imperative for the treating surgeon to maintain a high index of suspicion. Appropriate laboratory and imaging studies are invaluable in establishing a timely diagnosis. In the majority of patients, antibiotic treatment along with spinal immobilization has been shown to produce good long-term outcomes. Operative intervention is rarely necessary in patients failing conservative treatment.
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High rates of discitis following surgery for prolapsed intervertebral discs at a hospital in Pakistan.
OBJECTIVES: To confirm the presence of an outbreak of postoperative infections following laminectomy and to determine the infection rate after interventions were instituted. DESIGN: Retrospective cohort study. Medical records were reviewed, personnel interviewed, and premises examined. SETTING: Surgical unit of hospital A in Pakistan. SUBJECTS: Patients who had surgical laminectomy between January 1993 and July 1994. INTERVENTION: Instructive program for nursing and medical staff in December 1993. RESULTS: From January to December 1993, 6 (15%) of 41 laminectomy patients developed postoperative discitis. The risk of discitis varied significantly by surgeon (P = .016); patients who had one particular surgeon, surgeon A, were nine times more likely to develop postoperative infections than patients who did not have surgeon A. Patients were not consistently cleaned or shaved before coming to the operating room, and personnel moved back and forth between the operation theater and other parts of the hospital without changing their gowns or slippers. After the instructional intervention, between January and July 1994, 2 (6%) of 31 laminectomy patients developed postoperative discitis, a rate not significantly lower than in the preceding 12 months (P = .45). Overall, from January 1993 through July 1994, female patients were more likely to develop discitis than males (31% vs 7%; relative risk, 4.4; 95% confidence interval, 1.3-15.6; P < .032). CONCLUSION: Endemic conditions require that laminectomy at hospital A be limited to those situations where the benefits of the surgery exceed the considerable risk of postoperative discitis.
Cohort Studies↗