Surgical Approaches for Vertebral Osteomyelitis: A Systematic Review and Meta-analysis Comparing Anterior, Posterior, and Combined Techniques

Introduction: Pyogenic vertebral osteomyelitis is a serious infection of the spine with increasing incidence. While many cases can be managed conservatively, surgical intervention is often required for patients with neurological deficits, spinal instability, or failure of medical management. However, the optimal surgical approach remains controversial. This study aimed to synthesize the available evidence comparing outcomes between different management strategies and surgical techniques.

Methods: A systematic review and meta-analysis was conducted of studies comparing surgical and medical management of vertebral osteomyelitis. Primary outcomes included clinical deterioration, reoperation rates, length of hospital stay, and mortality. Secondary analysis compared outcomes between anterior, posterior, and combined surgical approaches.

Results: Thirty-eight studies with 1,885 patients were included. There were no significant differences between surgical and medical management in clinical deterioration (mean difference -0.0674, 95% CI: -0.172 to 0.038, p=0.208), reoperation rates (mean difference 0.0626, 95% CI: -0.032 to 0.157, p=0.195), length of stay (mean difference -0.045, 95% CI: -1.30 to 1.21, p=0.944), or mortality (mean difference 0.037, 95% CI: -0.0541 to 0.128, p=0.426). Anterior approaches were associated with the highest rates of improved clinical outcomes (71.2%) compared to posterior (63.8%) and combined approaches (5.45%), though differences were not statistically significant (p=0.347).

Conclusion : This meta-analysis found no significant differences in outcomes between surgical and medical management of vertebral osteomyelitis. Among surgical approaches, anterior techniques may be associated with better clinical outcomes, though high-quality comparative studies are needed to confirm these findings.