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July 31, 2026Open Access

Comparison of Hospital Mortality and Risk Factors in Conservative and Surgical Treatment of Pyogenic Vertebral Osteomyelitis: A Nationwide Analysis of 49,951 Cases in Germany

MSMelanie SchindlerUniversität für Weiterbildung Krems JSJosina StraubUniversity Hospital Regensburg JKJonas KrückelUniversity Hospital Regensburg

Key Points

The study aims to identify risk factors for in-hospital mortality in patients with vertebral osteomyelitis undergoing conservative or surgical treatment.
Registry-based retrospective cohort study analyzing hospital data from 2019 to 2023.
Cases identified using ICD-10 codes M46.20–M46.59 from a national dataset.
Demographics and treatment reviewed using diagnosis-related groups (DRG).
Among 49,951 cases, the in-hospital mortality rate was 6.7%.
Surgical treatment linked to higher mortality in patients aged ≥65 years (OR 1.47) and ≥80 years (OR 1.56).
Bacteroides fragilis infection showed an OR of 2.81 for higher mortality under conservative treatment.

Abstract

Study Design Registry-based retrospective cohort study. Objective Identify risk factors for in-hospital mortality in patients with vertebral osteomyelitis (VO) treated conservatively or surgically using a national dataset. Methods Hospital data from 2019 to 2023 were analyzed using the database of the German Institute for the Hospital Remuneration System (InEK). Cases were identified by ICD-10 codes M46.20–M46.59. Diagnosis-related groups (DRG) were used to analyze demographics and treatment. Results A total of 49,951 VO cases were identified, with an overall in-hospital mortality of 6.7%. The incidence of VO in Germany from 2020 to 2023 was 46.2 cases per 100,000 population. VO in the cervicothoracic (OR 2.31), thoracolumbar (OR 2.88), lumbosacral (OR 2.60) and multifocal (OR 3.93) regions was associated with increased in-hospital mortality. Conservative treatment was linked to higher mortality in intraspinal abscesses (OR 1.9) and multifocal disease (OR 2.29). In unadjusted, treatment-stratified analyses, surgical treatment was associated with higher in-hospital mortality in patients aged ≥65 years (OR 1.47) and ≥80 years (OR 1.56). Regarding pathogens, the highest mortality ORs were observed in patients infected with Bacteroides fragilis and other anaerobic gram-negative bacteria (OR 2.81, conservative treatment) as well as Haemophilus influenzae (OR 2.00, surgical treatment). In the pooled risk-factor analysis, Pseudomonas aeruginosa carried the highest pathogen-associated in-hospital death (OR 2.01). Conclusions This nationwide analysis identifies factors associated for in-hospital mortality in VO. Conservative management, though most common, carries increased risk in high-risk settings such as epidural abscesses or multifocal disease. In unadjusted analyses, surgical treatment in elderly patients was associated with higher in-hospital mortality. Because treatment was not randomly allocated and surgical patients differ systematically in disease severity, this association is likely confounded by indication and cannot be read as a treatment effect. Findings underscore the need for individualized, risk-adapted strategies and for adjusted, longitudinal studies.

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