OBJECTIVE:We review the results of treatment of a series of patients with spinal osteomyelitis, to formulate a systematic and comprehensive approach to the management of this disease in light of recent technical and conceptual advances in imaging, spinal biomechanics, and internal fixation.METHODS:We retrospectively reviewed the records for 57 consecutive patients with pyogenic spinal osteomyelitis who were treated between June 1987 and June 1995. Pain and weakness were the most common presenting symptoms. The mean duration of symptoms at the time of diagnosis was 10.6 weeks. Surgical indications included the presence or development of motor deficits with epidural compression and/or localized kyphotic deformities or the failure of medical therapy.RESULTS:Thirty-three patients underwent surgery as their initial treatment. Six additional patients experienced medical therapy failure and received subsequent surgical treatment. Seventeen patients were treated using an anterior approach only, 13 were treated using a posterior approach only, and 9 were treated using a combined anterior and posterior approach. After a minimal follow-up period of 24 months, 93% of the surgically treated patients showed neurological improvement or were neurologically intact, with a mean 16-degree decrease in localized kyphotic deformities and with solid bony fusion and resolution of pain for all patients.CONCLUSION:Early surgical decompression results in rapid improvement of neurological deficits, decreases in kyphotic deformities, and stabilization with bony fusion. The presence of active infection does not preclude the use of internal fixation. Nonsurgical management is indicated for patients with minimal or no neurological deficits and the absence of significant localized kyphotic deformities. However, 25% of patients who were initially treated nonsurgically experienced medical therapy failure and underwent surgical treatment.