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Endoscopic Decompression Can Be Effective for Diagnosing and Treating Tubercular Spondylodiskitis with Early Epidural Spinal Compression: A Retrospective Study of 18 Cases

Authors:
  • Atlas Copco India

Abstract

Study design: Retrospective study. Purpose: In this study, we describe an endoscopic method of effectively treating tubercular lumbar spondylodiskitis with early onset epidural spinal cord compression in the lumbar spine on magnetic resonance imaging (MRI). Overview of literature: Percutaneous aspiration and biopsy of spondylodiskitis under ultrasonography and computer tomography scan invariably provides an inadequate diagnosis. Methods: From May 2015 to May 2017, 18 patients presented with intractable back pain and were diagnosed with tubercular spondylodiskitis on MRI; these patients were enrolled in this study. The goal was to confirm the pathogen on biopsy, drain the abscess, and perform debridement. Chemotherapy was started after histologic diagnosis, and data collected included blood cell counts, erythrocyte sedimentation rate, C-reactive protein, and repeat MRI after 3 months. Results: Mean duration of surgery was 52 minutes. Mean follow-up was 17 months. The average preoperative Visual Analog Scale score of 8 (range, 6-10) decreased to 3 (range, 1-8) postoperatively. Tubercular spondylodiskitis was observed in 14 cases; two cases were pyogenic, and the biopsy was inconclusive in two cases. After adequate chemotherapy, no recurrences were noted. Conclusions: We hereby conclude that endoscopic biopsy and drainage can provide a better diagnosis and decrease pain in a predictable manner.
Tubercular Spondylodiskitis, Endoscopic Biopsy
Asian Spine JournalAsian Spine Journal
803
Endoscopic Decompression Can Be Eective
for Diagnosing and Treating Tubercular
Spondylodiskitis with Early Epidural Spinal
Compression: A Retrospective Study of 18 Cases
Abhijit Pawar, Chirag Manwani, Raghavendra ete, Mihir Bapat, Vishal Pesheiwar, Satishchandra Gore
Center for Bone and Joint, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
Study Design: Retrospective study.
Purpose: In this study, we describe an endoscopic method of effectively treating tubercular lumbar spondylodiskitis with early onset
epidural spinal cord compression in the lumbar spine on magnetic resonance imaging (MRI).
Overview of Literature: Percutaneous aspiration and biopsy of spondylodiskitis under ultrasonography and computer tomography
scan invariably provides an inadequate diagnosis.
Methods: From May 2015 to May 2017, 18 patients presented with intractable back pain and were diagnosed with tubercular spon-
dylodiskitis on MRI; these patients were enrolled in this study. The goal was to conrm the pathogen on biopsy, drain the abscess,
and perform debridement. Chemotherapy was started after histologic diagnosis, and data collected included blood cell counts, eryth-
rocyte sedimentation rate, C-reactive protein, and repeat MRI after 3 months.
Results: Mean duration of surgery was 52 minutes. Mean follow-up was 17 months. The average preoperative Visual Analog Scale
score of 8 (range, 6–10) decreased to 3 (range, 1–8) postoperatively. Tubercular spondylodiskitis was observed in 14 cases; two cases
were pyogenic, and the biopsy was inconclusive in two cases. After adequate chemotherapy, no recurrences were noted.
Conclusions: We hereby conclude that endoscopic biopsy and drainage can provide a better diagnosis and decrease pain in a pre-
dictable manner.
Keywords: Tubercular spondylodiskitis; Endoscopic debridement; Infective spondylodiskitis; Psoas abscess; Biopsy
Copyright 2018 by Korean Society of Spine Surgery
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Asian Spine Journal • pISSN 1976-1902 eISSN 1976-7846 • www.asianspinejournal.org
Received Sep 29, 2017; Revised Dec 5, 2017; Accepted Jan 9, 2018
Corresponding author: Abhijit Pawar
Center for Bone and Joint, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Andheri West, Mumbai 400053, India
Tel: +91-7387080391, Fax: +91-2230972030, E-mail: drabhijitpawar@gmail.com
ASJASJ
Clinical Study Asian Spine J 2018;12(5):803-809 • hps://doi.org/10.31616/asj.2018.12.5.803
Asian Spine JournalAsian Spine Journal
Introduction
Spondylodiskitis is an infection involving the interverte-
bral discs, end plates, or vertebral body. Early diagnosis
and prompt management is crucial for managing spinal
infections [1-3]. Spinal tuberculosis (TB) is the most
common extrapulmonary form of TB, and it can cause
severe pain, neuro deficits, and deformities [4]. Despite
various treatment approaches, the management of spinal
TB remains challenging. Tubercular spondylodiskitis is
being diagnosed with increasing frequency due to greater
availability of magnetic resonance imaging (MRI) [1].
Resistance to rst-line antitubercular drugs has been ob-
served in approximately 12% of cases [4]. Hence, biopsy
Abhijit Pawar et al.804 Asian Spine J 2018;12(5):1-809
is crucial for confirming the diagnosis anddetermining
patient sensitivity to antitubercular therapies. Percuta-
neous aspiration and biopsy under ultrasonography or
computer tomography (CT) scan has a variable success
rate of 36%–91% inpatients with infective spondylodiski-
tis [5-7]. Aspirates are oen inadequate, and no organism
is cultured. Percutaneous endoscopic discectomy was
first used for the treatment of uncomplicated herniated
discs in the early 1980s [8]. Minimally invasive manage-
ment approaches are gradually gaining popularity due to
their increased effectiveness and higher safety margins.
Percutaneous endoscopic discectomy and debridement is
a simple technique that is eective for debriding the disc
space and features a diagnostic accuracy of 45%–87%, ac-
cording to the organism isolated [9-11]. With the rise in
immunosuppressed patients due to human immunode-
ciency virus or chronic diseases, the incidence of multi-
drug-resistant tubercular spondylodiskitis is increasing,
and biopsies are required to diagnose and determine the
sensitivity and resistance of the disease to various drugs
[12]. We retrospectively evaluated 18 patients diagnosed
with tubercular spondylodiskitis on MRI who were treat-
ed with endoscopic debridement and discectomy. This
technique provides not only an adequate tissue sample but
also signicant symptom relief.
Materials and Methods
Aer approval of the Institutional Review Board of Koki-
laben Dhirubhai Ambani Hos pital, Mumbai (IRB ap-
proval no. KH0127), we enrolled 18 patients with intrac-
table back pain, no neuro decits, and early onset epidural
spinal cord compression on lumbar spine MRI. Most of
the patients complained of unremitting back pain, which
disturbed their sleep and was not relieved by rest or anal-
gesics. ere were 12 females and six males with average
age of 46 years, range 22–68 from May 2015 to May 2017.
e inclusion criteria included a diagnosis of tubercular
spondylodiskitis based on clinical examination and ra-
diographic and MRI findings, and elevated erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP).
Patients with neuro deficits and spinal deformities were
excluded from the study. Six patients had received antitu-
bercular treatments (ATT) prior to the surgery and had
experienced subsequent worsening of pain; consequently,
ATT was stopped 1 week before endoscopy in these pa-
tients. e other 12 patients did not receive any antibiotics
before surgery and until the biopsy results were available.
The surgical indication was intractable back pain and
clinically worsening leg pain in patients who had not
responded to chemotherapy and in whom MRI showed
single-level spondylodiskitis with epidural spinal com-
pression, a psoas abscess, or a paravertebral abscess. e
goal of the surgery was to conrm the pathogen on biopsy
and drain the abscess. Depending on each patient’s symp-
toms and location of the abscess on MRI (right or left),
the approach was decided.
Surgery was performed under local anesthesia and se-
dation, thereby making the procedure safe for high-risk
patients. Under fluoroscopic guidance, the entry point
was marked, and a long spinal needle was inserted in the
aected disc space within the lumbar spine. e position
of the guide wire was confirmed in both anterior–poste-
rior and lateral views. e guide wire was passed, and the
position conrmed. Stab incision was taken and, a dilator
and canula were passed into the disc space (Fig. 1). A Karl
Storz spinal endoscope was passed over the dilator into the
appropriated disc space under C-arm guidance, and a bi-
opsy was obtained with punch forceps. Following this, the
abscess was drained and wash given with normal saline.
Debridement was performed with discectomy forceps
(Fig. 1). Decompression was performed until the dura and
traversing nerve root were visualized. Because of the 12th
rib, it is technically dicult to install a dilatation sleeve in
the disc space at D12–L1; however, grasper forceps and
an endoscopy hook can easily reach the disc space. The
dilation sleeve and endoscopy sheath can be placed in the
disc space between L2–S1. All specimens were sent for mi-
croscopy, genetic and histopathological diagnosis as well as
culture. Normal saline was used for irrigation and debride-
ment throughout the procedure. In each patient, more than
enough tissue was obtained after biopsy without the fear
of specimen dilution. Since the procedure was performed
endoscopically without any bleeding, no drain was placed.
No intraoperative or perioperative complications were
observed in any of these cases. Postoperatively, the patients
mobilized with either an LS belt or T-L Corset, depending
on the location of the lesion. Postoperatively serial X-ray
are taken for all the patients at 3-month intervals. In two
patients, progression of the deformity was seen, and these
two patients underwent subsequent surgery for stabiliza-
tion of spine. Chemotherapy was started after diagnosis,
and all the patients were monitored with blood cell counts,
ESR, CRP, and repeat MRI aer 3 months.
Tubercular Spondylodiskitis, Endoscopic Biopsy
Asian Spine JournalAsian Spine Journal
805
Table 1. Patients details and outcomes at 1 year
No. Age (yr) Sex Site of
infection Culture Preoperative
VAS score
Postoperative VAS
score at 3 months Outcome at 1 year
1 46 F L1–L2
M. tuberculosis
8 3 Healed with ATT
2 32 F L4–5
S. aureus
7 3 Healed with antibiotics
322 M D12–L1
M. tuberculosis
94 Healed with ATT
4 64 M L1–L3 No growth 6 2 Healed on ATT
5 43 F L4–5
M. tuberculosis
7 2 Healed on ATT
6 49 M D12–L1
M. tuberculosis
9 8 Needed decompression and fusion
7 41 F L1–L2
M. tuberculosis
10 4 Healed on ATT
8 61 F L3–4
M. tuberculosis
7 2 Healed on ATT
9 45 M L2–3
M. tuberculosis
7 0 Healed on ATT
10 32 M L2–3
M. tuberculosis
8 1 Healed on ATT
11 28 F L2–3
M. tuberculosis
9 2 Healed on ATT
12 65 F L1–2
M. tuberculosis
10 3 Healed on ATT
13 42 F L1–2
M. tuberculosis
7 8 Needed decompression and fusion
14 32 F D12–L1
M. tuberculosis
8 1 Healed on ATT
15 55 M L4–5
S. aureus
9 2 Healed with antibiotics
16 35 F L2–3
M. tuberculosis
7 1 Healed on ATT
17 46 M D12–L1
M. tuberculosis
7 1 Healed on ATT
18 54 F L1–L2 No growth 6 1 Healed on ATT
VAS, Visual Analog Scale; F, female; M, male;
M. tuberculosis, Mycobacterium tuberculosis; S. aureus, Staphylococcus aureus.
Fig. 1. (A–F) Technique of endoscopic decompression and debridement.
AB C
DE F
Abhijit Pawar et al.806 Asian Spine J 2018;12(5):1-809
Results
Eighteen cases (n=18) with lumbar spondylodiskitis and
abscesses on MRI were reviewed. ere were 12 females
and six males, with an average age of 46 years (range,
22–68 years), from May 2015 to May 2017. The mean
duration of surgery was 52 minutes (range, 45–80 min-
utes). Mean follow-up duration was 17 months (range,
10–24 months). e average preoperative Visual Analog
Scale (VAS) score was 8 (range, 6–10) but decreased to an
average postoperative score of 3 (range, 1–8). Tubercular
spondylodiskitis was observed in 14 cases; two cases were
pyogenic, and the biopsy was inconclusive in two cases
(Table 1).
Mycobacterium tuberculosis was isolated in 14 cases,
Staphylococcus aureus in two, and no pathogen in two.
We concluded that no organism was isolated in these two
patients because they had already received ATT; hence,
no organism could be isolated. Patients with tubercular
spondylodiskitis were started on an antitubercular treat-
ment for 1 year. e response to treatment was monitored
with complete blood cell, ESR, and CRP, repeated every 3
months. MRIs were repeated at 3–4 months of follow-up
visit and at 1 year aer the completion of ATT. Two pa-
tients with who were reported at tubercular spondylodis-
kitis on MRI but microbiology and culture conrmed the
presence of S. aureus. Both these patients responded to
appropriate antibiotic therapies. Two patients complained
A B
CD
Fig. 2. (A–D) A 32-year-old female with D12–L1 spondylodiskitis with psoas abscess and disabling back pain.
Tubercular Spondylodiskitis, Endoscopic Biopsy
Asian Spine JournalAsian Spine Journal
807
of persistent back pain and leg pain aer 1 year and un-
derwent surgery for spinal stabilization.
Discussion
In this study, patients with thoracolumbar (TL) and lum-
bar tubercular spondylodiskitis, with epidural abscess and
early spinal compression, were treated effectively with
endoscopic decompression and debridement, followed by
chemotherapy. Paravertebral and epidural abscesses were
drained, focal tissues were debrided, and sclerotic bones
were removed endoscopically. The procedures were per-
formed under local anesthesia and sedation without any
perioperative or postoperative complications. Sufficient
material was obtained from the infected disc region, with
a higher diagnostic accuracy (Figs. 2–5). Cultures were
negative in two patients, despite having sufficient tissue
for diagnosis. These two patients received ATT before
endoscopy, and this could be the reason for the negative
cultures. However, these patients later responded well to
ATT because drug penetration is probably better aer ef-
fective decompression. All the patients received ATT for
1 year post debridement. Two patients continued expe-
riencing worsening back pain and leg pain at follow-up
and underwent further decompression and instrumental
fusion. MRIs of two patients detected paravertebral and
epidural abscesses, and these patients were reported as
having tubercular spondylodiskitis, but subsequent mi-
crobiology and cultures showed S. aureus. ese patients
responded to appropriate antibiotics for 6–8 weeks. Iden-
tifying the pathogen with biopsy is critical for the eective
treatment of infectious spondylodiskitis [5,13,14]. The
accuracy of CT-guided biopsy varies from 36% to 91%,
according to various studies [1,5,11,15]. In a study con-
ducted by Foreman et al. [15], CT-guided biopsy showed
positive microbiology and histology results in only 28% of
cases. Fouquet et al. [6] reported positive results in 36% of
cases (nine of 25 patients). Yang et al. [11] compared CT-
guided biopsy to endoscopic biopsy for infectious spondy-
lodiskitis and experienced better results with endoscopy
(90% with endoscopy versus 47% with CT-guided proce-
dures). e biopsy results were positive in 16 cases (89%)
in the present study. e average preoperative VAS score
of 8 decreased to an average postoperative VAS score of
3. Endoscopic debridement, abscess drainage, inamma-
tory factor irrigation, and intradiscal pressure reduction
Fig. 3. (A–C) Postoperative magnetic resonance imaging at the 5-month follow-up with almost healed spondylodiskitis.
AB C
Fig. 4. (A–C) A 28-year-old female with intractable back and right leg
pain with spondylodiskitis at L2–L3 and right psoas abscess.
AB C
Abhijit Pawar et al.808 Asian Spine J 2018;12(5):1-809
contributed to the immediate and signicant decrease in
VAS scores. Fourteen patients diagnosed with M. tubercu-
losis on biopsy had normal MRIs and no back or leg pain
at the 1-year follow-up. Aer the completion of ATT, two
patients continued to experience worsening back and leg
pain and were treated with posterior decompression and
fusion.
With advancements in technology, CT-guided biopsy
or ultrasound-guided biopsy is performed frequently in
suspected cases [2,11,16]. Although the positive yield has
increased, we still face issues of inconclusive results due
to inadequate biopsy samples, inadequate symptom relief,
and radiation exposure [1,3,5,7]. Although open biopsy
has a higher rate of detection, it comes with its own set
of problems, including the need for general anesthesia,
which might be contraindicated inpatients with multiple
comorbidities, increased risk of surgical site infection, and
delayed recovery [2,4,16]. One of the biggest advantages of
endoscopic biopsy and drainage is that along with obtain-
ing adequate tissue sample, under direct visualization, ab-
scess drainage facilitates symptom relief for patients [9,17].
Because the procedure is performed under local anesthe-
sia and sedation, it can be performed even in high-risk
patients. e rate of secondary surgical interventions can
be reduced with adequate debridement and antitubercular
therapies. Whether the duration of antibiotic therapy can
be decreased using this technique still remains a question.
This study has several limitations. The retrospective
nature of the study, small number of cases (n=18), and
short follow-up duration are among the most notable. A
prospective study in a large population would validate
the feasibility of this technique. Another limitation of this
study is that this procedure was performed for spondyl-
odiskitis of the lumbar spine and TL junction. It is techni-
cally dicult to perform this technique at the cranioverte-
bral junction and within the cervical spine. Although the
TL junction and lumbar spine are the most commonly in-
volved regions, with future advances, it might be possible
to treat patients with cervical spine diskitis in a similar
manner.
Conclusions
Endoscopic discectomy and debridement can be eective
for the diagnosis of tubercular spondylodiskitis and can
reduce pain in these patients. It can be an eective tool for
treating elderly patients with multiple medical comorbidi-
ties as it can be performed under local anesthesia. The
debridement of necrotic tissue is performed under direct
visualization, and extensive anterior or posterior spinal
decompression and instrumentation can be avoided. is
technique can be an effective tool within the armamen-
tarium of the spine surgeon for treating infective tubercu-
lar spondylodiskitis without deformities or neurological
involvement.
Conict of Interest
No potential conict of interest relevant to this article was
reported.
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AB C
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... If significant publication bias was found, the Duval and Tweedie trim and fill method was used to adjust for the possible bias. bridement and drainage (PEDD), which is coupled with less complications and satisfactory clinical outcome, provides a minimally invasive surgical choice for the treatment of spinal infection (7)(8)(9)(10)(11)(12). ...
... Among 1,581 retrieved searched articles, 9 singlearm PEDD articles (7)(8)(9)(10)(11)(15)(16)(17)(18) were with a total of 158 included patients (Fig. 1). All of the 9 studies were retrospective. ...
... However, surgical intervention is always associated with more complications, although overall mortality is lower in operated patients (1). PEDD, which is coupled with less complications and satisfactory clinical outcome, provides a minimally invasive surgical choice for the treatment of spinal infection (7)(8)(9)(10)(11)(12). ...
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Identifying offending pathogens is crucial for appropriate antibiotic administration for infectious spondylitis. Although computed tomography (CT)-guided biopsy for bacteriologic diagnosis is a standard procedure, it has a variable success rate. Some reports claim percutaneous endoscopic discectomy and drainage offer a sufficient amount of tissue for microbiologic examination and easy application. We therefore compared the diagnostic value of CT guidance with that of endoscope guidance in 52 patients with suspected infectious spondylitis. Twenty patients underwent percutaneous endoscopic discectomy and drainage by an orthopaedic surgeon and the other 32 patients underwent CT-guided biopsies by a radiologist. Patients were followed a minimum of 12 months after treatment. Culture results of the biopsy specimens were recorded. Causative bacteria were identified more frequently with percutaneous endoscopy than in CT-guided biopsy (18 of 20 [90%] versus 15 of 32 [47%]). We observed no biopsy-related complications or side effects in either group. The data suggest percutaneous endoscopic discectomy and drainage yield higher bacterial recovery rates than CT-guided spinal biopsy. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Background: The diagnostic value of CT-guided spinal biopsy in patients with suspected spondylodiscitis is reported inconsistently in the literature. Our aim was to evaluate associations between procedural, clinical and imaging parameters and the diagnostic yield of CT-guided spinal biopsy. Methods: 102 procedures performed in 87 patients with clinically suspected spondylodiscitis were analyzed retrospectively. Pre-procedural MR and CT images were evaluated regarding signal alterations, vertebral destruction and soft-tissue involvement. The position of the biopsy needle in correlation with MR imaging findings was assessed. Patient characteristics and clinical details were noted. Parameters were compared in patients with positive and negative microbiological and histological results. Results: Based on microbiology and histology, infectious spondylodiscitis was diagnosed in 29 and 23 biopsies, respectively. Microbiology results were significantly higher in biopsies with central needle positioning within contrast enhancing tissue in correlation with the MR images (36% vs. 7%; p = 0.005). Biopsies positioned in fluid-equivalent hyperintense discs in T2-weighted sequences yielded significantly lower microbiology results (6% vs. 33%; p=0.036). Purely lytic endplate destruction and mixed vertebral density as shown by CT increased microbiology results (60% vs. 24%; p = 0.028). Previous antibiotic treatment for any cause did not influence microbiology yields significantly (p=0.232). Conclusions: MRI is mandatory to determine the optimal biopsy position. No clinical or imaging parameter could rule out a positive biopsy result and thus omit an unnecessary procedure. Biopsying should not be refrained from if antibiotic treatment has previously been administered.
Article
I retrospectively reviewed the records of 111 patients who had pyogenic vertebral osteomyelitis unrelated to an open procedure on the spine. The mean age at the time of the diagnosis was sixty years (range, eighteen to eighty-four years); sixty-one patients (55 per cent) were sixty years old or more. Forty-four patients (40 per cent) had an impaired immune system secondary to diabetes mellitus, the use of corticosteroids, chemotherapy for cancer, rheumatic or immunological disease, renal or hepatic failure, malnutrition, or myelodysplasia. Magnetic resonance imaging, critical for the determination of an early diagnosis, was performed for 103 patients (93 per cent). The infection in sixty-eight patients (61 per cent) was diagnosed within one month after the onset of symptoms. The most frequent infecting organism was Staphylococcus aureus (forty patients; 36 per cent). The infection in forty-one patients (37 per cent) was caused by organisms, such as Staphylococcus epidermidis, Propionibacterium acnes, and diphtheroid species, that are traditionally considered to be of low virulence. The urinary tract was the most frequent source of infection (confirmed in thirteen patients and suspected in twenty-one). The success of non-operative treatment was predicted by four independent variables: an age of less than sixty years, the immune status, infection with Staphylococcus aureus, and a decreasing erythrocyte sedimentation rate. Forty-two patients were managed with debridement and arthrodesis. Fourteen of these patients also had instrumentation of the spine, in the presence of infection, without compromise of the outcome. Eighteen patients died by the time of the latest follow-up evaluation at a mean of four years (range, two years and two months to six years and six months): seven who had been managed non-operatively died in the first month after the diagnosis was made, three died in the acute postoperative period, three died of late complications of paraplegia, and five died of unrelated causes. None of the eighty-nine patients who were seen at a minimum of two years postoperatively had had late recurrence of infection. Chronic, severe back pain was noted in only seven patients.
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Two major types of postoperative discitis have been previously described: septic discitis and "avascular" or "chemical" discitis. Percutaneous discal biopsy is an important way of distinguishing these entities. In a retrospective study of 25 cases of postoperative discitis, three groups have been analyzed with bacteriologic and histologic tests: a group of nine patients (group A) with positive discal bacteriologic cultures; a group of eight patients (group B) with typical septic histologic tests but negative bacteriologic discal procedures; and a group of eight patients (group C) in whom the histologic picture was reminiscent of a mechanical process. No group was unique in any clinical and radiologic parameter. Group A and group B were quite similar in biological features, but group C had erythrocyte sedimentation rate and C-reactive protein serum levels significantly lower than groups A and B (P < 0.01). After 4 weeks, these differences were still present. This study confirms that there are two main features of postoperative discitis that can be recognized by histologic and biological tests, allowing for different treatments.
Article
Two major types of postoperative discitis have been previously described: septic discitis and "avascular" or "chemical" discitis. Percutaneous discal biopsy is an important way of distinguishing these entities. In a retrospective study of 25 cases of postoperative discitis, three groups have been analyzed with bacteriologic and histologic tests: a group of nine patients (group A) with positive discal bacteriologic cultures; a group of eight patients (group B) with typical septic histologic tests but negative bacteriologic discal procedures; and a group of eight patients (group C) in whom the histologic picture was reminiscent of a mechanical process. No group was unique in any clinical and radiologic parameter. Group A and group B were quite similar in biological features, but group C had erythrocyte sedimentation rate and C-reactive protein serum levels significantly lower than groups A and B (P less than 0.01). After 4 weeks, these differences were still present. This study confirms that there are two main features of postoperative discitis that can be recognized by histologic and biological tests, allowing for different treatments.