Comparing Conservative and Early Surgical Treatments for Pyogenic Spondylodiskitis: An International Propensity Score-Matched Retrospective Outcome Analysis

BACKGROUND AND OBJECTIVES: Pyogenic spinal infections pose therapeutic challenges, with the optimal treatment approach remaining contentious. This study aimed to compare outcomes of conservative vs early surgical treatment (SuT) modalities in primary pyogenic spondylodiskitis through an international cohort analysis. METHODS: A retrospective outcome analysis was conducted of 392 patients from the United Kingdom and Germany, treated between 2017 and 2022 with primary pyogenic spondylodiskitis. Patients were stratified by treatment modality. Propensity score matching, facilitated by a directed acyclic graph and principal component analysis, was used to balance risk factors between the compared patient cohorts. Primary outcome was mortality rate, while secondary outcomes included hospitalization duration, infection relapse, and neurological status at discharge. RESULTS: The study included 95 patients undergoing conservative treatment, primarily treated in the United Kingdom, and 297 receiving SuT, predominantly in Germany. The mortality rate was notably higher in the conservative group (P <.001), while the surgical cohort experienced a shorter hospitalization duration (P <.01). After propensity score matching, 2 comparable cohorts of 95 patients each emerged. Subsequent analysis revealed a markedly increased mortality in the conservative group (24.2% for conservative treatment vs 4.2% for SuT, P <.001). Neither relapse nor neurological status at discharge showed significant differences between the groups. CONCLUSION: The study indicates that early surgical intervention may be more effective than conservative management in reducing mortality and hospital stay for patients with primary pyogenic spondylodiskitis. These findings highlight the need for prospective trials and more definitive treatment guidelines.