Stability, neurology, infection, and morbidity (SNIM): The quest towards a unified framework for assessment and management of spinal infection:A narrative review and position paper of the EANS spondylodiscitis study group.

BACKGROUND

Primary spinal infections - including spondylodiscitis, vertebral osteomyelitis and epidural abscess - are increasingly prevalent and clinically heterogeneous, yet no standardized assessment or treatment guidelines currently exist. This position paper proposes a structured framework to support clinical evaluation and management and to guide future trials.

MAJOR FINDINGS: Based on a comprehensive literature review and expert consensus, the authors identify four core domains essential for spinal infection evaluation: Stability, Neurology, Infection, and Morbidity (SNIM). Stability is assessed through clinical and radiographic indicators such as vertebral destruction, deformity, and pain. Neurological deficits-including radicular weakness or myelopathy-remain key indications for decompression, supported by imaging of neural compression. Infection control depends on accurate pathogen identification, targeted antimicrobial therapy, and, when indicated, surgical debridement or abscess drainage. Morbidity, including age, frailty and comorbidities, modifies treatment strategies and influences conservative and surgical outcomes, necessitating tailored, risk-adapted approaches. Building on these domains, the paper formulates testable hypotheses related to surgical interventions and introduces a conceptual treatment algorithm designed to reduce clinical heterogeneity and inform prospective study design.

CONCLUSION

The SNIM framework is presented as a preliminary model intended to harmonize terminology, support trial development, and structure future research. While not a validated classification system, it provides a foundation for stratifying patients and exploring outcome-relevant variables. The proposed algorithm reflects current expert interpretation and is offered as a hypothesis-generating tool to be refined through collaborative validation efforts. This paper aims to stimulate ongoing research and multidisciplinary engagement in the evolving field of spinal infection management.