Introduction: Coccidioidomycosis is an invasive fungal disease that may present with extra-thoracic dissemination. Patients with spinal coccidioidomycosis require unique medical and surgical management considerations. The authors review the risk factors and clinical presentations, discuss the indications for surgical intervention, and evaluate outcomes and complications after medical and surgical management of these patients.
Methods: A systematic review of the English-language literature was performed. Data from 18 articles included the management of 140 patients with spinal coccidioidomycosis.
Results: Risk factors for spinal coccidioidomycosis included male gender (95%), African American ethnicity (52%), and a recent visit to endemic areas (16%). The most frequent clinical presentation was pain (57%), followed by evidence of neurological compression (52%). Only one-third of patients had concurrent pulmonary disease. The sensitivity of culture and histology for coccidioidomycosis was 80% and 90%, respectively. In spinal disease, complement fixation titers >1:128 suggest extensive or refractory vertebral infection. The most commonly affected spinal segments were the thoracic and lumbar spine (65%), with additional epidural and paravertebral abscesses (28%). All patients received mono- or polytherapy with azoles (60%) or Amphotericin B (43%). Surgical and medical management were used conjunctively to treat 79% of patients, with debridement (95%, 105/110) and fusion (64%, 70/110) being the most common surgical procedures. Clinical outcome improved or remained unchanged in 59% of cases and worsened in 3%, and the mortality rate was 7%. Infection recurrence and disease progression were the most frequent complications.
Conclusions: Emphasis should be placed on continuous and life-long appropriate azole therapy. Spinal instability and neurological compromise are surgical indications for decompression, debridement, and fusion.
Patient Care: . In most cases, surgical intervention is needed in patients with neurological compromise or deformity, and it provides better outcomes and mortality rates. Continuous and lifelong azole therapy after surgery when appropriate reduces the risk of recurrence, especially in patients with high CF titers.
Learning Objectives: this is the first systematic review on the surgical and medical management of patients with spinal coccidioidomycosis , including the conjoint experience of the Neurosurgical and Infectious Diseases departments at out institution in an endemic area for this pathology.