Treatment of infections of the spine

Long-Term Clinical and Radiologic Outcome Following Surgical Treatment of Lumbar Spondylodiscitis: A Retrospective Bicenter Study

BACKGROUND AND STUDY AIMS

 Spinal instrumentation for spondylodiskitis (SD) remains highly controversial. To date, surgical data are limited to relatively small case series with short-term follow-up data. In this study, we wanted to elucidate the biomechanical, surgical, and neurologic long-term outcomes in these patients.

MATERIAL AND METHODS

 A retrospective analysis from two German primary care hospitals over a 9-year period (2005-2014) was performed. The inclusion criteria were (1) pyogenic lumbar SD, (2) minimum follow-up of 1 year, and (3) surgical instrumentation. The clinical and radiologic outcome was assessed before surgery, at discharge, and at a minimum of 12 months of follow-up. Follow-up included physical examination, laboratory results, CT and MRI scans, as well as assessment of quality of life (QoL) using short-form health survey (SF-36) inventory, Oswestry Disability Questionnaire, and visual analog scale (VAS) spine score.

RESULTS

 Complete data were available in 70 patients (49 males and 21 females, with an age range of 67±12.3 years) with a median follow-up of 6.6 ± 4.2 years. Follow-up data were available in 70 patients after 1 year, in 58 patients after 2 years, and in 44 patients after 6 years. Thirty-five patients underwent posterior stabilization and decompression alone and 35 patients were operated on in a two-stage 360-degree interbody fusion with decompression. Pre- and postoperative angles of the affected motion segment were 17.6 ± 10.2 and 16.1 ± 10.7 degrees in patients with posterior instrumentation only and 21.0 ± 10.2 and 18.3 ± 10.5 degrees in patients with combined anterior/posterior fusion. Vertebral body subsidence was seen in 12 and 6 cases following posterior instrumentation and 360-degree instrumentation, respectively. Nonfusion was encountered in 22 and 11 cases following posterior instrumentation and 360-degree instrumentation, respectively. The length of hospital stay was 35.0 ± 24.5 days. Surgery-associated complication rate was 18% (12/70). New neurologic symptoms occurred in 7% (5/70). Revision surgery was performed in 3% (2/70) due to screw misplacement/hardware failure and in 3% (2/70) due to intraspinal hematoma. Although patients reported a highly impaired pain deception and vitality, physical mobility was unaffected and pain disability during daily activities was moderate.

CONCLUSION

 Surgical treatment of SD with a staged surgical approach (if needed) is safe and provides very good long-term clinical and radiologic outcome.

Transforaminal Lumbar Interbody Fusion with Antibiotics Delivered by CaSO4 Drug Carrier System for Pyogenic Spondylodiscitis

BACKGROUND

Spondylodiscitis is a challenging spinal disorder that requires surgical treatment only as a last resort. The use of various procedures and instruments remains controversial. In this retrospective study, we reported the safety and efficacy of a CaSO₄ drug carrier system for the transforaminal lumbar interbody fusion (TLIF) procedure for lumbar pyogenic spondylodiscitis.

METHODS

Thirty-four patients with lumbar spondylodiscitis underwent TLIF. CaSO₄ beads carrying vancomycin and gentamycin were implanted in the trajectory of screws and disc spaces. We measured markers of inflammation, scores of neurologic recovery, and quality of life. The fusion status was assessed at final follow-up and the correction of local and total lordotic angle was calculated.

RESULTS

The patients were followed up for at least 12 months (range, 12-24 months). At 3 months follow-up, C-reactive protein levels and erythrocyte sedimentation rate returned to normal with no relapse. Nineteen patients with American Spinal Injury Association grade D preoperatively returned to American Spinal Injury Association grade E. The improvement on the visual analog scale and Oswestry Disability Index was 66.9% and 84.9%, respectively. At 12 months follow-up, 67.6% of patients achieved definitive union. The corrections of total and local lordotic angle were 10.02° ± 8.77° and 7.7° ± 8.75°, respectively. The rate of achievement of satisfactory Kirkaldy-Willis functional criteria was 85.3%.

CONCLUSIONS

The combined use of single-level TLIF with a CaSO₄ drug delivery system was safe and effective for treatment of pyogenic lumbar spondylodiscitis. The system promoted reduction of inflammation with limited fixed segments without a negative impact on fusion status. This procedure may be considered a novel choice for spondylodiscitis, with more efficacy and less invasion.

Safety and efficacy of polyetheretherketone (PEEK) cages in combination with posterior pedicel screw fixation in pyogenic spinal infection

BACKGROUND

To date, there is growing consensus that PEEK material may be used for interbody fusion in spinal infections. Data supporting that claim are however restricted to a few very small clinical series. The aim of this study is to evaluate the outcome of surgical treatment of pyogenic spinal infections with PEEK cages in combination with posterior pedicel screw fixation.

METHODS

Between 2006 and 2013, a total of 211 patients suffering from spondylodiscitis underwent surgical debridement and instrumentation. There were 52 cases where PEEK cages were used. Laboratory and physical examinations were assessed at a 3-month follow-up. Last follow-up was performed with at a minimum of 12 months after surgery via a telephone interview.

RESULTS

Mean age at presentation was 67 years, with 19 (37 %) male patients and 33 (63 %) female. Distribution of the infection was lumbar in 29 (56 %%), thoracic in 3 (6 %) and cervical in 11 (21 %) cases. Nine patients (17 %) had concomitant non-contiguous spondylodiscitis. Epidural abscess was found in 17 patients (33 %); 48 (92 %%) had pain; neurological deficits were found in 20 patients (38 %). All patients in this series underwent surgical debridement with instrumentation of the spine. Postoperative intravenous antibiotics were administered for 15.4 ± 6.8 days followed by 2.9 ± 0.5 months of oral antibiotics. Complete resolution of the infection was achieved in all cases. Of the 28 patients with neurological deficits, 6 had full recovery and 10 had improved incompletely after surgery. One patient suffered from a pulmonary embolism postoperatively. There were no mortalities.

CONCLUSIONS

Use of PEEK cages for interbody fusion is feasible and safe in patients suffering from a pyogenic spinal infection.