Global consensus on spinal infections: lessons from the International Consensus Meeting 2025

A global challenge that requires a global response

Spinal infections represent a broad group of conditions with substantial differences in causative organisms, pathology, clinical progression, and treatment requirements. A patient with pyogenic spondylodiscitis caused by Staphylococcus aureus presents a clinical scenario that differs greatly from a patient with spinal tuberculosis. Yet in many discussions, these conditions have historically been grouped together as "spinal infection."

This approach has limitations. The biological behavior of tubercular disease differs significantly from that of pyogenic infection. Diagnostic pathways vary, treatment duration varies, surgical indications vary, and outcomes and complications differ. Applying a single classification or treatment philosophy across these entities can create confusion rather than clarity.

One of the most important achievements of the ICM process was the decision to evaluate pyogenic and tubercular spinal infections through separate consensus pathways. This distinction reflects what many surgeons encounter in daily practice, particularly in regions where both disease types coexist.
The need for such discussions is amplified by large differences in healthcare infrastructure worldwide. Access to advanced imaging, molecular diagnostics, multidisciplinary infection teams, specialized surgical care, and prolonged antimicrobial treatment varies widely. A recommendation that is feasible in one healthcare system may not be easily implemented in another.

For that reason, any global guideline must balance scientific evidence with real-world applicability. That was a central principle throughout the consensus process.

Moving beyond individual experience

The challenge of limited evidence

Many aspects of spinal infection care suffer from a lack of high-level evidence. Randomized studies are uncommon, patient populations are heterogeneous, and disease severity varies substantially at presentation. As a result, surgeons often rely on personal experience, institutional protocols, or regional practice patterns.

This creates variability in areas such as:

• Timing of surgery
• Choice of surgical approach
• Instrumentation in infected environments
• Duration of antibiotic therapy
• Diagnostic workup strategies
• Indications for biopsy
• Follow-up imaging protocols

While expert opinion remains valuable, variation can create uncertainty for surgeons attempting to establish consistent treatment algorithms.

Building practical recommendations

The strength of the ICM process was its ability to harness collective expertise from a large international community. More than 300 clinically relevant questions were initially proposed by participating surgeons. Through structured review and prioritization, these were refined to 73 high-impact questions that reflected areas of significant uncertainty.

The process encouraged transparent discussion and systematic evaluation of available evidence. More importantly, it focused attention on questions that clinicians confront every day rather than highly specialized situations encountered only occasionally. The final recommendations therefore aim to complement clinical judgment.

Consensus and clinical practice

One concern sometimes raised about consensus statements is whether they risk oversimplifying complex clinical scenarios. Our experience was quite the opposite.

The ICM discussions highlighted the many situations in which patient-specific decision-making remains essential. Factors such as neurological status, mechanical stability, virulence of the pathogen, extent of bone destruction, medical comorbidities, and local resources all influence management decisions.

Consensus creates a common starting point but does not eliminate the flexibility needed. For example, a shared framework for evaluating spinal instability in infection can improve communication among surgeons while still allowing individualized treatment decisions. Similarly, recommendations regarding diagnostic pathways can help reduce delays without preventing clinicians from adapting strategies to local circumstances.

The goal is consistency in principles rather than uniformity in clinical action.

Implications for surgeons managing pyogenic infection

Earlier diagnosis and structured evaluation

Delayed diagnosis remains one of the most significant contributors to poor outcomes in pyogenic spinal infection. Numerous studies have highlighted the importance of early recognition, appropriate imaging, microbiological confirmation when possible, and timely treatment. 

The consensus process reinforced the importance of standardized evaluation pathways that include clinical assessment, laboratory investigations, imaging, and microbiological diagnosis whenever feasible.

For surgeons, this can help reduce unnecessary delays and facilitate earlier multidisciplinary involvement.

Surgical decision-making

Surgery remains a critical component of treatment in selected patients. Progressive neurological deficit, instability, deformity, failure of medical treatment, and uncontrolled infection continue to be important indications.

What emerged from the discussions was recognition that surgical timing can significantly influence outcomes. Increasing evidence supports early intervention in appropriately selected patients rather than prolonged observation when clear surgical indications already exist.

The consensus recommendations provide a framework for evaluating these decisions while recognizing that patient factors and resource availability remain important determinants.

Tubercular spinal infection deserves separate consideration

In many parts of the world, tuberculosis remains one of the most common causes of spinal infection. Despite this, global discussions frequently focus more heavily on pyogenic disease and the ICM deliberately addressed this imbalance.

Tubercular spondylitis presents unique challenges: the disease often progresses more slowly, can involve multiple vertebral levels, has less pain and inflammation, often has huge cold abscess and may result in significant deformity before diagnosis. Drug therapy is prolonged, and surgical goals often extend beyond infection control to include neural decompression, deformity correction, and preservation of long-term spinal balance.

By treating tuberculosis as a distinct topic within the consensus framework, the recommendations better reflect the realities faced by surgeons in regions where spinal tuberculosis remains endemic. This separation also avoids the risk of applying management principles from pyogenic disease to a condition with fundamentally different biological behavior.

A model for future guideline development

Perhaps the most enduring contribution of the ICM will be the process itself, not any single recommendation. Orthopaedic and spine surgery face many areas where practice variation exceeds the available evidence base. Surgeons frequently manage complex conditions where randomized trials are limited or absent. In such settings, structured international collaboration can play an important role.

The ICM model demonstrates how large groups of experts can evaluate evidence, identify areas of agreement, openly discuss controversies, and develop practical recommendations that clinicians can apply across diverse environments.

The process was transparent, reproducible, and inclusive. It allowed surgeons from different regions and healthcare systems to contribute equally to the conversation. For future guideline development in orthopaedics and spine care, this may be one of the most valuable lessons from the meeting. 

Looking ahead

The management of spinal infections will continue to challenge spine surgeons. Advances in molecular diagnostics, imaging technology, antimicrobial strategies, and surgical techniques will undoubtedly influence future practice. Yet patients will still require timely diagnosis, thoughtful decision-making, and individualized care and the ICM 2025 recommendations provide a foundation for that effort.

As surgeons, our responsibility is to combine the best available evidence with clinical experience and local realities. The consensus recommendations offer a common language that can help us achieve that goal while maintaining flexibility for the wide range of situations encountered in practice.

Most importantly, they represent a collective commitment from the global spine community to improve outcomes for patients affected by some of the most complex conditions we treat.