Is Conservative Treatment Superior to Surgical Intervention in Hematogenous Primary Septic Spinal Infection in Terms...

Background/Objectives: The treatment of Hematogenous Primary Septic Spinal Infection (HPSSI) typically involves either conservative management or surgical intervention. Previous studies have suggested that conservative treatment with antibiotics is the mainstay conventional procedure in treating HPSSI, but relevant conclusions remain controversial regarding mortality, recurrence, and hospital stay. There is a lack of systematic reviews and meta-analyses comparing conservative vs. surgical treatment specifically in non-TBC, non-fungal, and non-postsurgical HPSSI in adults. This systematic review and meta-analysis aim to systematically evaluate the therapeutic effectiveness of conservative versus surgical intervention for the management of HPSSI, through a meta-analysis of key outcomes including mortality, recurrence, and length of hospital stay. Methods: A comprehensive literature search was performed across four major databases: PubMed, Cochrane, Science Direct, and Scopus. Using defined inclusion and exclusion criteria, we identified twelve studies encompassing 1199 patients with hematogenous, primary, septic spinal infection, which was not post-surgical, not due to TBC, and not fungal, who were treated conservatively (n = 519) or surgically (n = 680) for inclusion in the meta-analysis. PRISMA guidelines were used for this analysis. The primary outcome analyzed was mortality; secondary outcomes were infection recurrence and length of hospital stay, comparing conservative treatment versus operative intervention for HPSSI. Results: Mortality rates for surgical versus conservative treatment varied across five studies. Some studies reported significantly lower mortality with surgical intervention vs. conservative treatment (2.3-6% vs. 17.8-18%), while others showed no difference (11% for both treatments). This meta-analysis indicates that surgical treatment does not significantly alter mortality rates compared to conservative management, although study heterogeneity is considerable. Infection recurrence was reported in three studies, with rates ranging from 5 to 16.4% for conservative treatment and 5 to 11.6% for surgical intervention. These differences were not statistically significant in studies that provided group-specific data. Findings on hospital length of stay were mixed: two studies reported shorter stays for surgical patients (23.9-33.4 days vs. 40.5-51.2 days), while another study found no meaningful difference between the groups. Across multiple studies, advanced age, frailty, higher comorbidity burden, and neurological impairment were consistently identified as independent predictors of increased mortality, irrespective of treatment modality. Although some data suggest a short-term survival advantage associated with surgical intervention, the overall mortality outcomes remain heterogeneous across the literature. Conclusions: Overall, the findings of this meta-analysis remain inconclusive regarding which treatment-surgical or conservative-is more advantageous in reducing mortality, infection recurrence, and hospital stay. The variability across studies highlights the influence of patient selection, treatment protocols, and local clinical practices. To enhance our understanding and improve outcomes in HPSSI, future randomized controlled trials are essential. These studies should incorporate clear selection criteria, standardized terminology for spinal infection subgroups, and homogenous patient populations with well-defined comorbidities to allow for meaningful data comparisons. Additionally, emphasis should be placed on early diagnosis, rapid identification of causative pathogens, using modern diagnostic tools, and timely initiation of appropriate treatment-whether surgical or conservative-to optimize patient outcomes, including reduced mortality, lower recurrence rates, and shorter hospitalizations.