Prophylaxis of postoperative lumbar spondylodiscitis

Postoperative Lumbar Pyogenic Spondylodiscitis: An Institutional Review

Background   Postoperative discitis (POD) remains a dreaded complication in the present era of asepsis. The treatment has been traditionally conservative, but the safety of spinal implants in infective settings has prompted the surgeons to provide rigid immobilization for promoting healing. A major concern in a country like ours is huge patient inflow and long waiting list added to the woe of patient's refusal for a second operative intervention after a first undesirable outcome. Objectives  The aim of the study was to evaluate the functional and radiological outcome of conservative management of POD and determine the methods of prevention. Settings and Design   A retrospective case study series in a tertiary-level hospital. Materials and Methods   Between January 2015 and 2017, 12 cases of POD (10 own and 2 referred) were managed and followed up clinically, radiologically, and with laboratory investigation. Two cases were managed surgically-one with kyphotic deformity and the other with discharging pus. Rest were managed conservatively with analgesics and intravenously followed by oral antibiotics. At 1-year follow-up, patient satisfaction was evaluated using the MacNab outcome assessment. Statistical Analysis   The descriptive data were analyzed mainly by descriptive statistics using mean, median, standard deviation, and interquartile range. Results   Mean follow-up in our series was 15.2 months. Except for two operated cases, we did not go for the invasive procedure for isolation of organism in any of our cases. The total duration of antibiotic in our series was for the mean of 7.3 weeks. Visual analog scale score returned from8 initially to baseline and at final follow-up-4 excellent, 6 good, and 2 had fair outcome. There was no adverse outcome. Conclusions   The majority of POD can be managed conservatively. Surgery is reserved only for special cases. Magnetic resonance imaging is the investigation of choice for diagnosing discitis. Intraoperative use of gentamicin-mixed normal saline wash reduces the incidence of discitis.

Pyogenic discitis following discectomy

PURPOSE

To assess the treatment outcome for disc infection in 35 patients.

METHODS

Records of 23 men and 12 women aged 36 to 62 (mean, 43) years who underwent treatment for pyogenic discitis after open discectomy were reviewed. All patients had single-level disc herniation of L4-5 (n=28) or L5-S1 (n=6), except for one who had 2-level disc herniation of L4-S1. Single antibiotic was given one day prior to discectomy and continued for 2 days. All excised discs were found to be sterile. Discitis was classified into acute (n=26), subacute (n=7), and chronic (n=2). Antibiotic therapy was started immediately when the clinical diagnosis was made. 31 patients were treated with antibiotics alone; the remaining 4 underwent surgery entailing simple posterior superficial wound drainage (n=1), anterior radical surgery (n=2), or posterior instrumentation and posterolateral fusion for post-discectomy syndrome (n=1). Six of the 12 patients who had percutaneous disc space aspiration underwent disc space irrigation.

RESULTS

The initial symptoms included mild-to-moderate fever (n=4), severe back pain (n=27), back muscle spasms (n=26), back pain radiating to the limb (n=2), Gower sign (n=11), and a draining wound (n=1). The wound aspirates of the 12 patients grew organisms, although blood cultures were negative in all. After antibiotic therapy, symptoms gradually subsided in parallel with normalisation of white blood cell count and inflammatory markers. Surgery was indicated only when symptoms worsened and the disease progressed. Spontaneous intercorporal fusion did not occur.

CONCLUSION

Early diagnosis and treatment with appropriate antibiotics is important for post-discectomy discitis.

Postoperative spondilodiscitis

INTRODUCTION

Postoperative spondylodiscitis is a primary infection of the nucleus pulposus with secondary involvement of the cartilaginous endplate and vertebral bone. Although uncommon, postoperative spondylodiscitis causes major morbidity and may be associated with serious long-term sequelae. Several risk factors had been identified, including immunosuppression, obesity, alcohol, smoking, diabetes and malnutrition.

MATERIALS AND METHODS

A review of the literature was done to analyse the diagnosis, treatment and prevention of postoperative spondylodiscitis.

RESULTS

We found that the principles of conservative treatment are to establish an accurate microbiological diagnosis, treat with appropriate antibiotics, immobilise the spine, and closely monitor for spinal instability and neurological deterioration. The purpose of surgical treatment is to obtain multiple cultures of bone and soft tissue, perform a thorough debridement of infected tissue, decompress neural structures, and reconstruct the unstable spinal column with bone graft with or without concomitant instrumentation.

CONCLUSIONS

Appropriate management requires aggressive medical treatment and, at times, surgical intervention. If recognised early and treated appropriately, a full recovery can often be expected. Therefore, clinicians should be aware of the clinical presentation of such infections to improve patient outcome. A review of the literature was done to advance our understanding of the diagnosis, treatment, prevention and outcome of these infections.

Spondylodiscitis after lumbar microdiscectomy: effectiveness of two protocols of intraoperative antibiotic prophylaxis in 1167 cases

The role of antibiotic prophylaxis in preventing postoperative lumbar spondylodiscitis is still controversial in medical, ethical, economic, and legal terms. The aim of this retrospective study was to evaluate the efficacy of two intraoperative antibiotic prophylaxis protocols in a large series of lumbar microdiscectomies performed in two different neurosurgical centres. We reviewed the outcome of 1167 patients operated on for a lumbar disc herniation with microsurgical technique, in order to detect the incidence of postoperative spondylodiscitis. Group A included 450 patients operated on in a 3-year period in the Neurosurgical Division of the University Hospital of Ancona; group P consisted of 717 patients operated on in a 4-year period in the Neurosurgical Division of the Sandro Pertini Hospital of Rome. In both groups intraoperative antibiotics for prophylaxis were administered, whereas postoperative prophylaxis was not performed. Protocol of group A: single intravenous dose of cefazoline 1 g at induction of general anesthesia and generous washing with saline solution and irrigation with a solution containing rifamicin at the end of microsurgical procedure. Protocol of group P: single-dose of intravenous ampicillin 1000 mg and sulbactam 500 mg at induction of anesthesia and generous irrigation with saline solution at the end of microsurgical procedure. A diagnosis of postoperative spondylodiscitis was made in three out of 450 patients in group A (0.67%) and in 5 out of 717 patients in group P (0.69%). In all cases, treatment consisted of rigid thoraco-lumbar orthesis and 4- to 6-week administration of amoxicillin/clavulanate compound (500/125 mg). The low incidence of postoperative spondylodiscitis obtained with both our protocols seems to confirm that intraoperative antibiotic prophylaxis is associated with the same rate of discitis of prolonged prophylaxis usually still adopted in many centres, but is more advantageous both in terms of welfare and comfort for patients and in economic terms. However, at the moment it is not possible identify the ideal antibiotic for this purpose. It seems to be reasonable to search for the solution through large multicenter prospective studies.

Postoperative discitis due to Propionibacterium acnes: a case report and review of the literature

BACKGROUND

No previous report has described a progressive, destructive postoperative discitis requiring operative stabilization due to Propionibacterium acnes. The clinical and radiographic features and treatment options associated with discitis due to P acnes are presented in a retrospective case study, as well as a review of the current literature.

CASE DESCRIPTION

Seven weeks after a routine lumbar discectomy, the patient presented with clinical findings and radiographic imaging consistent with discitis. Intraoperative cultures obtained from irrigation and debridement of the disc space revealed P acnes, and appropriate intravenous antibiotic treatment was instituted. Approximately 2 months later, the patient showed progression to a destructive osteomyelitis requiring operative stabilization. Nine weeks after stabilization, the patient continued to have lower back pain without radiculopathy. Laboratory values had normalized. Radiographic imaging revealed good instrumentation positioning and adequate fusion. The patient was ambulatory with bilateral articulating ankle foot orthoses and a walker.

CONCLUSION

The reported case adds to the literature on postoperative discitis due to P acnes and demonstrates that this organism can occasionally be the cause of progressive, destructive osteomyelitis. In addition, we review the incidence, risk factors, and clinical course of discitis due to P acnes.

Intraoperative antibiotic prophylaxis in clean spinal surgery: a retrospective analysis in a consecutive series of 973 cases

BACKGROUND

Antibiotic prophylaxis in spine surgery is still a debated question, involving medical, ethical, economic, and legal issues. The aim of our retrospective study was to evaluate the safety and effectiveness of an intraoperative protocol of antibiotic prophylaxis.

METHODS

During a 3-year period, 973 patients were consecutively operated on for clean spinal operations. Twenty-three percent of the cases involved the cervical spine and 77% the thoraco-lumbar spine; about 90% of patients were operated on for degenerative diseases and the remaining for traumatic lesions or tumors. Patients undergoing operations shorter than 120 minutes received a single-dose of IV ampicillin 1000 mg and sulbactam 500 mg (AS) at induction of anesthesia. In procedures longer than 120 minutes and/or requiring prosthetic materials, an IV single-dose of teicoplanin 400 mg was also administered at the same time. A second intraoperative dose of AS and teicoplanin was administered in operations longer than 4 hours (240 minutes after the first one) and in procedures in which blood loss exceeded 1500 mL. Postoperative prophylaxis has never been performed.

RESULTS

The only side effect was a cutaneous rash in 7 cases (0.7%), without any consequence. A wound infection was detected in 9 cases (<1%), all successfully treated with surgical toilette and specific antibiotic treatment. A lumbar discitis was detected in 4 out of 657 microdiscectomies (0.6%).

CONCLUSIONS

Even if this study has the weakness of the retrospective character, our intraoperative antibiotic prophylaxis protocol proved to be safe and efficacious. We hope that these preliminary results will be confirmed by larger prospectic trials.

Spondylodiscitis after lumbar discectomy. Incidence and a proposal for prophylaxis

STUDY DESIGN

An analysis of the incidence of spondylodiscitis after lumbar disc surgery in 1642 patients. In 508 patients no prophylactic antibiotics were given. In 1134 patients a collagenous sponge containing gentamicin was placed in the cleared disc space.

OBJECTIVES

To report the incidence of postoperative spondylodiscitis in cases in which no antibiotic prophylaxis was used, and to define the value of a collagenous sponge containing gentamicin in preventing disc space infections.

SUMMARY OF BACKGROUND DATA

Spondylodiscitis is considered to be a rare complication of lumbar disc surgery. The retrospective design of most studies and the rare use of magnetic resonance imaging for early radiologic diagnosis suggest that the reported incidence rates may be underestimates. Postoperative spondylodiscitis is the result of intraoperative contamination and, theoretically, could be prevented by treating these patients with prophylactic antibiotics.

METHODS

In 1642 patients, 1712 discectomies were performed. In 508 of these patients no prophylactic antibiotics were given; in 1134 of these patients a collagenous sponge containing gentamicin was placed in the cleared disc space. Clinical reexamination and, in cases of unsatisfactory results, laboratory and radiologic investigations were performed 4-8 weeks after surgery.

RESULTS

In nineteen of the 508 patients who were not treated with antibiotic prophylaxis (3.7%) a postoperative spondylodiscitis developed, whereas none of the 1134 patients who received antibiotic prophylaxis became symptomatic (P < 0.00001).

CONCLUSION

In the current study, a 3.7% incidence of postoperative spondylodiscitis was found in the absence of prophylactic antibiotics. Gentamicin-containing collagenous sponges placed in the cleared disc space were effective in preventing postoperative spondylodiscitis.

The C-reactive protein for detection of early infections after lumbar microdiscectomy

The tendency for short hospitalization after lumbar microdiscectomy implies the need for early confirmation or disapproval of serious postoperative infections such as spondylodiscitis or deep wound infections. The C-reactive protein (CRP) is a well-known screening parameter for monitoring postoperative infectious complications in other fields. Our objective was to establish the diagnostic significance of CRP-in comparison with ESR and WBC-for monitoring infectious complications after lumbar microdiscectomy. Over a 15 months period we studied prospectively a homogeneous group of N = 400 patients with lumbar disc herniations who were operated on a single level for the first time. CRP, ESR and WBC values were determined in all patients pre-operatively, and on postoperative days 1 and 5. Clinical and laboratory findings were correlated and the diagnostic significance of CRP, ESR and WBC calculated. N = 385 (96%) patients had an uneventful postoperative course. N = 15 (4%) patients developed infectious complications, of which N = 6 (1.5%) were unrelated and N = 9 (2.5%) related to surgery. Evaluation of the laboratory values showed: The CRP baseline is a very individual value of no prognostic relevance. A high postaggression peak is typical and essential as a reference value for only the future time course will disclose any infection. We found 0% false negative and 4% false positive results on day 5. The sensitivity for serial CRP testing was calculated as 100% and specificity as 95.8%. ESR (sensitivity: 78.1%/specificity: 38.1%) and WBC (sensitivity: 21.4%/specificity: 76.8%) both failed to reach such distinct diagnostic significance on day 5. The C-reactive protein has thus proved to be a reliable, simple and economical screening test for infectious complications after lumbar microdiscectomy, superior to classical laboratory parameters.

Spondylodiscitis after lumbar disk surgery

The value of perioperative prophylactic use of antibiotics in lumbar disc surgery is investigated, based on a retrospective study of the operative results of 5041 patients. The rate of occurrence of postoperative spondylodiscitis was significantly higher during the period in which no perioperative prophylaxis was carried out, than it was during the period, in which perioperative prophylaxis was routine. Thus the perioperative prophylactic use of antibiotics seems highly recommendable.

Prognosis in postoperative discitis. A retrospective study of 111 cases

111 cases of postoperative discitis during 1968-1986 were analyzed retrospectively. The diagnosis was confirmed by lumbar tomography. Low back pain appeared at an average of 16 days postoperatively. Laboratory findings were of minor value in the diagnosis since elevated ESR, white blood cell count, and body temperature were inconstant findings. Compared with a matched control group, there was a higher incidence of chronic low back pain and vocational handicap in the discitis patients. There was no difference in the consumption of analgetics, the subjective evaluation of the final outcome, spinal mobility or neurologic findings.