Eur Spine J. 2016 Apr;25(4):1012-20. doi: 10.1007/s00586-015-3936-8.
Spondylodiscitis severity code: scoring system for the classification and treatment of non-specific spondylodiscitis.
- 1Centre for Spinal Cord Injuries, BG-Kliniken Bergmannstrost, Halle (Saale), Germany. firstname.lastname@example.org.
- 2Asklepios Clinic Weißenfels, Naumburger Straße 76, 06667, Weißenfels, Germany. email@example.com.
- 3Centre for Spinal Cord Injuries, BG-Kliniken Bergmannstrost, Halle (Saale), Germany.
- 4Department of Trauma, Hand and Reconstructive Surgery, Friedrich Schiller University Jena, Jena, Germany.
Established treatment options of spondylodiscitis, a rare but serious infection of the spine, are immobilization and systemic antibiosis. However, the available data for specific treatment recommendations are very heterogeneous. Our intention was to develop a classification of the severity of spondylodiscitis with appropriate treatment recommendations.
MATERIALS AND METHODS:
From 10/1/1998 until 12/31/2004, 37 cases of spondylodiscitis were examined regarding medical history, gender status, location and extent of spondylodiscitis, type and number of operations. Subsequently, a classification of six grades according to severity has been developed with specific treatment recommendations. The further evaluation of our classification and corresponding treatment modalities from 1/1/2005 to 12/31/2009 including further 132 cases, resulted in a classification of only three grades of severity (the SSC–spondylodiscitis severity code), with a follow-up until 12/31/2011. Between 01/01/2012 and 12/31/2013, a prospective study of 42 cases was carried out. Overall, 296 cases were included in the study. 26 conservatively treated cases were excluded.
RESULTS AND CONCLUSION:
The main localization of spondylodiscitis was the lumbar spine (55%) followed by the thoracic spine (34%). The classification of patients into 3 grades of severity depends on clinical and laboratory parameters, the morphological vertebral destruction seen in radiological examinations and the current neurological status. Therapies are adapted according to severity and they include a specific surgical management, systemic antibiotic therapy according to culture and sensitivity tests, physiotherapy and initiation of post-hospital follow-up. 40.6% of patients are associated with neurological deficits, classified as severity grade 3 and treated surgically with spinal stabilization and decompression. 46.9% of patients corresponded to severity grade 2, with concomitant vertebral destruction were dorsoventrally stabilized. The 31 patients of severity Grade 1 were treated surgically with dorsal stabilization. From 1998 to 2013, the time from the onset of symptoms to the first surgical treatment was about 69.4 days and has not changed significantly. However, the time from admission to surgical treatment had been reduced to less than 2 days. Also the time of hospitalization was reduced and we see positive effects regarding the sensation of pain. 270 patients underwent surgery. We treated 89% dorsally and 21% dorsoventrally. With the spondylodiscitis severity code, a classification of the severity of spondylodiscitis could be established and used for a severity-based treatment. In addition, specific parameters for the treatment of individual grades of severity can be determined in a clinical pathway.
Classification of severity; Paraplegia; Scoring system; Spondylodiscitis
A spondylodiscitis scoring system: SponDT – Spondylodiscitis Diagnosis and Treatment
Spondylodiscitis is a chameleon among infectious diseases due to the lack of specific symptoms with which it is associated. It is nevertheless a serious infection, with 7% mortality of hospitalised patients, in large part because of delayed diagnosis. The aim of this study was to develop a diagnosis and course-of-disease index to optimise its treatment.
Material and methods
Through analysis of 296 patients between January 1998 and December 2013, we developed a scoring system for spondylodiscitis, which we term SponDT, (Spondylodiscitis Diagnosis and Treatment) based on three traits: (I) the inflammatory marker C-reactive protein (CRP) (mg/dl), (II) pain according to a numeric rating scale (NRS) and (III) magnetic resonance imaging (MRI), to monitor its progression following treatment.
The number of patients receiving treatment increased over the past 15 years of our study. We also found an increasing age of patients at the point of diagnosis across the study, with an average age of 67.7 years. In 34% of patients, spondylodiscitis developed spontaneously. Almost 70% of them did not receive treatment until first diagnosis using SponDT. Following treatment against spondylodiscitis, pain intensity decreased from 6.0 to 3.1 NRS. The inflammatory markers also decreased (CRP from 119.2 to 46.7 mg/dl). Similarly, MRI revealed a regression in inflammation following treatment. By employing SponDT, patients were diagnosed and entered into treatment with a score of 5.6 (severe spondylodiscitis) and discharged with a score of 2.4 (light/healed spondylodiscitis).
In summary, our studies show that the combination of several diagnostic parameters into a single scoring system, SponDT, facilitates the diagnosis of spondylodiscitis. In combination with the Spondylodiscitis Severity Code (SSC), a classification of the severity of spondylodiscitis, SponDT could be established and used for a severity-based treatment. In addition, specific parameters for the treatment of individual grades of severity can be determined in a clinical pathway .
MRI and laboratory inflammatory markers are essential to this scoring system. While the latter retain their diagnostic importance in monitoring the course of treatment of spinal osteomyelitis, the use of MRI is not justified in cases of spondylodiscitis arising from surgical treatment of the spinal region; rather, clinicians should resort to the use of CT for monitoring the progression of spondylodiscitis. We stress that subjective pain perception is an integral and important parameter of SponDT for treatment evaluation. SponDT can be used in both the initial diagnosis of spondylodiscitis as well as in disease progression during treatment.
Figure 1, SponDT recording at admission to hospital and during the course of treatment; * = p <0.05
Additionally, the SponDT was developed as a course monitoring tool . It summarizes the clinical, paraclinical and morphological extend of spondylodiscitis (tab 1). Grades of severity were determined according to the SponDT score value and the Spondylodiscitis severity code. The classification of severity resulted in respective therapies (tab 2).
Table 1, Spondylodiscitis scoring system for diagnosis and therapy control using SponDT
Table 2, Spondylodiscitis severity code (SSC)
Figure 2. SponDT as parameter for the course of spondylodiscitis by subgroups, *=p<0.05
• The subjective pain level or the course of inflammatory markers (CRP, white blood count) showed no difference between the two groups.
- • The subjective pain level (NRS) decreased from 6.6 on admission to 3.7 at discharge.
- • The CRP dropped from 118.6 mg/dl to 30.1 mg/dl.
• SponDT as a parameter for the course of spondylodiscitis was not different (fig 4).
Randomized evaluation of Advantages of IT-based clinical pathways in surgical treatment of spondylodiscitis
Purpose: The German health care system increasingly incorporates clinical pathways as a tool to organize surgical, intervention or conservative therapies. Does a computerized clinical pathway offer advantages in severity-based surgical therapy of spondylodiscitis?
Methods: A hospital has adopted a computerized system based on three severity grades of spondylodiscitis. From 01/01/2012 to 12/31/2013, 32 patients with spondylodiscitis were randomly chosen at admission and prospectively analysed with regard to duration, costs of treatment, pain level and inflammatory markers.
Results: Of the 32 patients treated for spondylodiscitis who had not been transferred from another facility, 17 (53%) were treated according to a clinical pathway based on three well-established treatment regimens dependent on severity. The SponDT, as a parameter for the course of disease, was initially slightly higher in the pathway patient‘s group (6.82) than in the control group (6.2). Compared to a control group (n=15) there were differences in the total duration of stay (17.2 vs. 26.0) and the number of blood samples taken (7 vs.10). No differences could be shown for the extent of documentation, the physical and neurological outcome, the level of pain or the course of inflammatory markers. The most prevalent germ was Staphylococcus aureus (18.8%). In 43.8% of the patients, no infectious agent could be detected. Material costs and personnel-costs were significantly reduced in the pathway group (12.076 €) compared to 21.341€ in the control group.
Conclusion: Clinical pathways are a multi-professional consensus of workflow and documentation when treating a particular disease. As a clinical and administrative management tool it enables the optimal utilization of resources and defines responsibilities. An IT-based form can be implemented in continuation of already existing treatment principles. The previous process and result quality remains unaffected. An economization of the treatment process can be achieved as well as a complete and legally safe documentation in the patient’s electronic health record.
Moreover, transparency is improved, which facilitates the initial training of new staff members, especially in hospitals with a high turnover of employees. Since IT-based pathways are an easy and practical tool for the evaluation of quality and economic efficiency, potential for improvement becomes apparent at an early stage.
For this reason, hospitals should implement IT-based clinical pathways within the hospital information system to optimize treatment processes.
• Pathway patients underwent surgery 3.4 days after admission
• control group patients after 8.8 days
• 30 patients underwent a dorsal stabilization with an internal fixator
• 3 pathway patients and 4 non-pathway patients underwent a decompression
• 2 patients, whose cervical spine was affected, underwent a ventral approach
• 7 patients received a two-stage dorso-ventral surgery
- the point of time varied between 31.5 and 37.5 days
• 75% of the patients were treated according to severity grade 1
• 25% according to grade 2.
• sepsis was causative in 19.4% of the cases
• foregone spine surgery in 16.1%
• vertebral body fracture in 3.2%
• systemic diseases in 3.2%
• Germs were
- Staphylococcus aureus (18.8%)
- E.coli (12.5%)
- Staphylococcus epidermidis (9.4%)
- Other infectious agents were found in 12.5%
- MRSA in 3.1%
- no proof of germs in 43.8% (All patients received a ct-guided or intraoperative biopsy- and/or blood culture)
• Clindamycin was chosen in 43.3%
• Ciprofloxacin in 20.0%
• Linezolid in 3.3%
• Other antibiotics in 26.7% and multiple combinations with clindamycin in 6.7%
Within the cost-effectiveness analysis the following types of costs were compared:
– personnel expenses for medical staff (physicians and nurses)
– employees of medical and functional service,
– material costs for drugs, implants, other medical requirements,
– personnel and non-personnel costs of the medical infrastructure (e.g. maintenance and repair, nursing management, pharmacy),
– non-medical infrastructure (e.g. building expenses, accommodation and energy costs, costs for insurances and administration)
The group of pathway patients showed a significant cost reduction in the area of personnel expenses (fig 3).
Figure 3, Cost Element Comparison by subgroups, *= p< 0.05, Legend:
2 – PK-PFLD medical staff costs
3 – PK-MTD / FD personnel costs of medical and functional service
7 – PK / SK-MIS personnel and material costs of medical infrastructure
8 – PK / SK-NMIS personnel and material costs not medical infrastructure
Moreover, there were significantly higher costs for anaesthesiological services and laboratory testing as well as additional diagnostics when treated without pathway (fig 4).
Figure 4, Cost Center Comparison by subgroups, *= p< 0.05
From the economic point of view it remains to be said, that a treatment of spondylodiscitis according to an IT-based pathway results in a total surplus of 11.529 €. Without pathway the surplus is reduced to 8.705€. The economic condition and increase of quality can be described by the Incremental Cost-Effectiveness Ratio (ICER) based on clinical parameters. This is an important parameter for the result of a cost-effectiveness analysis, which defines the differences in expenses and outcomes of both alternatives. Here, it shows for non-monetary parameters, such as the duration of stay and subjective pain perception, a positive value when treated according to the pathway.
- Advantages of IT-based clinical pathways in surgical treatment of non-specific spondylodiscitis. Homagk N, Jarmuzek T, Meisel HJ, Hofmann GO, Homagk L (2016) Journal of Hospital Administration (JHA) 2016, Vol. 5, No. 6
- Marmelstein D, Homagk N, Hofmann GO, Röhl K, Homagk L. [Adjuvant systemic antibiotic therapy for surgically treated spondylodiscitis]. Z Orthop Unfall. 2015 Apr;153(2):165-70.
- Homagk L, Wiesner I, Hofmann GO et al (2013) Are IT-based clinical pathways superior to hard-copy form? Zentralbl Chir. 138:64-69.
- Homagk L, Deml O & Hofmann GO (2012) IT-based clinical pathway as a routine tool in trauma surgery. Unfallchirurg. Dec;115(12):1076-1082.
- A Spondylodiscitis Scoring System: SponDT – Spondylodiscitis Diagnosis and Treatment. Homagk L, Homagk N, Meisel HJ, Hofmann GO, Marmelstein D (2016) JSM Spine 1(1): 1004.
- Randomized Evaluation of Advantages of IT-Based Clinical Pathways in Surgical Treatment of Spondylodiscitis. Homagk N, Jarmuzek T, Meisel HJ, Hofmann GO, Homagk L (2016). JSM Spine 1(1): 1002.