The study was conducted according to EQUATOR STROBE observational study guideline. After obtaining approval from the Clinical Research Ethics Committee of local board (2023/123), the files of patients diagnosed with vertebral osteomyelitis between December 2017, and January 2023, were retrospectively screened. The center of this study is a tertiary-care state hospital serving approximately 1.8 million people. There is only one other tertiary-care university hospital in the region.
After excluding thoracic and lumbar spondylodiscitis cases, cervical osteomyelitis were included in the study. All the patients were older than 18 years, and none had a history of malignancy. Patients with severe deformities, progressive neurological deficits and/or instability were also excluded due to necessity of surgical treatment. Patients who did not follow up regularly and had missing/incomplete data were excluded.
Diagnosis: Diagnosis and treatment plans for patients were determined by a multidisciplinary team consisting of infectious disease specialists, radiologists, physical therapists, pain specialists, and neurosurgeons. Following a comprehensive clinical history and physical examination, all patients underwent a series of tests, including complete blood count (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), QuantiFERON TB test, Brucella-specific agglutination tests, standing cervical X-rays, and contrast-enhanced MRI. Post-treatment response was monitored based on clinical improvement, CRP decline and long-term MRI contrast reduction. Additionally, deformity progression was tracked by monitoring the cervical lordosis angle on standing cervical X-rays.
Infection treatment
Monthly follow-up of the patients was carried out by infectious disease physcian until inflammation was resolved according to a control MRI. Teicoplanin + ciprofloxacin was given for three months in the presence of pyogenic involvement. In brucellosis, streptomycin + rifampicin + doxycycline was given for three weeks; then, streptomycin was stopped and the rifampicin + doxycycline treatment was applied for seven months (total treatment time was eight months). In pyogenic cases, if no clinical or radiological response is obtained at the end of the 2-month treatment and the QuantiFERON test is positive, the treatment is switched to isoniazid + rifampicin + ethambutol + pyrazinamide and this regime continued minimum 6 months. The cervical MRI images of all the patients were interpreted by the same radiologist and CRP response was monitored for infectious disease specialist.
Pain and functional treatment
After cure was achieved following antibiotherapy, all patients were first referred to the physiotherapy(PT). After physical therapy, patients with persistent pain were informed about medical pain treatment and interventional pain treatments. Patients were divided into two groups as interventional (group 1) and medical (group 2) according to their preferences.
Interventional Therapy (Group 1)
Trigger point injections are performed into the sternocleidomastoid (SCM) muscle and trapezius muscle. Painful tender points are identified through palpation, and 0.1–0.2 ml of lidocaine is injected using an insulin syringe. Additionally, bilateral medial branch blocks of the facet joints are performed at levels including those above and below the affected level due to spondylodiscitis. The procedure is guided by fluoroscopy, and for each facet joint, a combination of 0.5 ml of bupivacaine and dexamethasone is injected. (Fig. 1)
Figure 1: Lateral (A) and Antero-Posterior (B) Fluoroscopic Images of Medial Branch Block of the Facet Joint
Medical Therapy (Group 2)
For patients unwilling to undergo interventional treatment, duloxetine hydrochloride is initiated at a dose of 30 mg/day and increased to 60 mg/day after one month (Fig. 1).
Follow-up
Numerical Rating Scale (NRS) of the patients were recorded before treatment (NRS-0), after antibiotic treatment (NRS-1), after PT (NRS-2), and at six months after medical or interventional treatment (NRS-3). Neck Disabilitiy Index (NDI) and SF-12 scores were recorded before and at six months after the procedure. (Table 1).
Deformity Monitoring
Patients were monitored for the development of kyphosis secondary to spondylodiscitis using standing lateral cervical X-rays. The lordosis angles were measured from the radiographs taken at the time of diagnosis and one year after treatment. The groups were compared in terms of changes in lordosis.
Statistical analysis
IBM SPSS Statistics v. 22 (IBM SPSS, Turkey) software package was used for the statistical analyses of the data obtained from the research. The Shapiro-Wilk test was conducted to check whether the parameters were normally distributed. Descriptive statistical methods (mean, standard deviation, median and interquartile range, and frequency) were used to present the data. Independent quantitative parameters were compared between the groups using the Mann-Whitney U test. Dependent quantitative parameters were compared between the groups using the Wilcoxon test. The comparison of two independent variables that conformed to a normal distribution was made with Student t-test. P < 0.05 indicated statistical significance in all the analyses.