Percutaneous endoscopic debridement with percutaneous pedicle screw fixation for lumbar pyogenic spondylodiscitis: a preliminary study

Unique characteristics of bone union at the infected vertebrae after minimally invasive posterior fixation without bone grafting in thoracolumbar pyogenic spondylitis: a retrospective multicenter cohort study

BACKGROUND

The current study aimed to evaluate the bone union rate between infected vertebrae after minimally invasive posterior fixation without bone grafting in thoracolumbar pyogenic spondylitis.

METHODS

This retrospective multicenter cohort study evaluated 75 patients of posterior fixation for thoracolumbar pyogenic spondylitis that have been recorded at six relevant institutions from January 2016 to December 2022. Data on age, sex, location of infected vertebrae, number of infected disks, comorbidity, Pola classification, number of vertebrae fixed according to surgery, implant failure requiring revision surgery, and distance according to the type of infected vertebrae after surgery were evaluated. Further, their association with postoperative bone union was investigated > 12 months postoperatively.

RESULTS

Finally, 40 patients were included in the study. In total, 32 (80%) patients achieved bone union at the infected vertebrae after minimally invasive posterior fixation without bone grafting. The mean duration from surgery to union was 10.7 months. Twenty-six (65%) patients initially achieved bone union at the lateral and/or anterior bridging callus. Patients with multiple-level infected disks (33%, 2/6 patients) had a lower bone union rate than those with a single-level infected disk (88%, 30/34 patients) (p = 0.0095).

CONCLUSIONS

In 80% of patients, bone union at the infected vertebrae was achieved after minimally invasive posterior fixation without bone grafting in thoracolumbar pyogenic spondylitis. A total of 65% of the patients achieved initial bone union at the lateral and/or anterior bridging callus. Moreover, patients with multiple-level infected disks had a low bone union rate. Hence, the treatment strategy should be cautiously considered.

TRIAL REGISTRATION

This study was registered retrospectively and all procedures used in this study including the review of patient records were approved by the institutional review board.

Endoscopic Treatment of Thoracolumbar Spondylodiscitis: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic surgery is a minimally invasive procedure that has been shown to relieve intradiscal pressure, irrigation of inflammatory factors, and visual debridement, which are crucial for the successful treatment of spondylodiscitis. This study proposes a systematic review and meta-analysis to evaluate the effectiveness and safety of endoscopic treatment of thoracolumbar spondylodiscitis.

METHODS

Multiple databases were searched for studies involving thoracolumbar spondylodiscitis treated by endoscopic disc drainage with or without additional posterior fixation over the last 20 years. Studies that met the inclusion criteria, which included outcomes related to the percentage of cured infections, patient satisfaction, regression of inflammatory markers, and/or the percentage of adverse event rates, were included in the analysis. For each study, the percentage of patients who showed improvement or experienced an adverse event was abstracted and pooled in a meta-analysis.

RESULTS

Based on the search strategy and inclusion criteria, our systematic review and meta-analysis included 20 studies with 546 participants. The success rate was 89.4% (95% CI 83.1%-94.5%). The rate of major adverse events was 0.3%, while that of postoperative transient paresthesia was 2.6% (95% CI 0.8%-5.1%). The recurrence rate was 1.7% (95% CI 0.3%-4.0%), and revision surgery was 8.5% (95% CI 3.8%-14.6%). The causative pathogen diagnosis rate was 73.9% (95% CI 67.7%-79.8%), while progression of deformity was 3.7% (95% CI 0.2%-9.8%), and spontaneous fusion was 40.1% (95% CI 11.0%-73.3%).

CONCLUSIONS

Endoscopic discectomy for thoracolumbar spondylodiscitis has been shown to be a safe technique with satisfactory clinical outcomes and a high causative pathogen identification rate.

Case report of minimally invasive spinal endoscopic debridement and pedicle screw fixation for severe spinal infection of the lumbosacral spine

Background

Surgical treatment of spinal infections, refractory to medical treatments, is increasing in incidence. Here, we present a unique case of discitis secondary to an iatrogenic cause, spinal steroid injection, that resulted in acute neurology, ventral phlegmon, and osteomyelitis requiring multiple surgical interventions for treatment.

Case Description

With the adoption of minimally invasive spinal surgery, the patient underwent full endoscopic debridement and decompression at our hospital. The endoscopic technique offers a unique avenue to the anatomically difficult ventral phlegmon for surgical excision, cultures, and pathogen identification. The endoscopic debridement was paired with percutaneous pedicle screw fixation to stabilize the spine from the worsening bone destruction.

Outcome

The patient recovered well postoperatively, with the resolution of her neurological symptoms and improved mobility.

Conclusions

Full endoscopic spinal debridement and decompression is a powerful tool to manage severe spinal discitis and preliminary studies encourage its adoption in surgical practices.

Pedicle screw insertion into infected vertebrae reduces operative time and range of fixation in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis: a multicenter retrospective cohort study

BACKGROUND

Minimally invasive posterior fixation surgery for pyogenic spondylitis is known to reduce invasiveness and complication rates; however, the outcomes of concomitant insertion of pedicle screws (PS) into the infected vertebrae via the posterior approach are undetermined. This study aimed to assess the safety and efficacy of PS insertion into infected vertebrae in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis.

METHODS

This multicenter retrospective cohort study included 70 patients undergoing minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis across nine institutions. Patients were categorized into insertion and skip groups based on PS insertion into infected vertebrae, and surgical data and postoperative outcomes, particularly unplanned reoperations due to complications, were compared.

RESULTS

The mean age of the 70 patients was 72.8 years. The insertion group (n = 36) had shorter operative times (146 versus 195 min, p = 0.032) and a reduced range of fixation (5.4 versus 6.9 vertebrae, p = 0.0009) compared to the skip group (n = 34). Unplanned reoperations occurred in 24% (n = 17) due to surgical site infections (SSI) or implant failure; the incidence was comparable between the groups. Poor infection control necessitating additional anterior surgery was reported in four patients in the skip group.

CONCLUSIONS

PS insertion into infected vertebrae during minimally invasive posterior fixation reduces the operative time and range of fixation without increasing the occurrence of unplanned reoperations due to SSI or implant failure. Judicious PS insertion in patients with minimal bone destruction in thoracolumbar pyogenic spondylitis can minimize surgical invasiveness.

Pyogenic spondylitis caused by Escherichia coli: A case report and literature review

BACKGROUND

Pyogenic spondylitis is often manifested as atypical low back pain and fever, which makes it easy to be confused with other diseases. Here we report a case of pyogenic spondylitis and describe the diagnosis and treatment based on the related literature.

CASE SUMMARY

The reported case suffered from pyogenic spondylitis caused by Escherichia coli and complicated with bacteremia and psoas abscess. Acute pyelonephritis was initially diagnosed due to atypical symptoms. Symptoms were improved from antibiotic treatment while developing progressive lower limb dysfunction. One month post the admission, the patient underwent anterior lumbar debridement + autogenous iliac bone graft fusion + posterior percutaneous screw-rod internal fixation, and received 6 wk of antibiotic treatment after the operation. Reexamination 4 mo post the operation showed that the patient had no evident pain in the waist, and walked well with no evident dysfunction of lower limbs.

CONCLUSION

Here we describe the application value of several imaging examinations, such as X-ray, computed tomography and magnetic resonance imaging, and certain tests like erythrocyte sedimentation rate and C-reactive protein in the clinical treatment of pyogenic spondylitis. This disease requires early diagnosis and treatment. Sensitive antibiotics should be used in early stages and surgical intervention should be taken if necessary, which may help for a speedy recovery and prevent the occurrence of severe complications.

Bibliographic Study and Meta-Analysis of Clinical Outcomes of Full-Endoscopic Spine Surgery for Painful Lumbar Spine Conditions

BACKGROUND

Full-endoscopic spine surgery (FESS) indications already cover degenerative, infectious, and neoplastic diseases. This study aimed to use a bibliometric search and meta-analysis of the highest-quality studies in the last 20 years to determine the quantity and quality of FESS research, geographic distribution, and the outcomes for lumbar conditions.

METHODS

Articles on FESS published from 2000 to 2022 were screened and assessed through Web of Science, PubMed, and Scopus. Also, databases were searched for longitudinal studies to pool in a meta-analysis of patients undergoing FESS for lumbar conditions. After stratifying the risk of bias and having collected the studies of the highest quality, we included the proportion of patients with a satisfactory outcome and intraoperative and postoperative adverse events after the analysis of lumbar spine conditions.

RESULTS

A total of 728 articles were identified by the bibliographic search. Between 2000 and 2021, the published articles increased 21-fold. Most were from China (70.15%), followed by South Korea (19.5%). Most were retrospective (68.3%) and regarding treatment of lumbar disease (86.4%). Fifty studies, including 34,828 patients, were pooled in the meta-analysis. More than 85% of patients experienced satisfactory improvement in each of different lumbar conditions. Major adverse events were <2%; recurrence and postoperative dysesthesia rates were within those reported for open or mini-invasive procedures.

CONCLUSIONS

This study may fill research gaps on FESS and lead to adequately designed studies. Our meta-analysis showed that FESS for lumbar diseases is a procedure with satisfactory outcomes and low rates of adverse events.

Percutaneous Versus Open Pedicle Screw Fixation for Pyogenic Spondylodiscitis of the Thoracic and Lumbar Spine: Systematic Review and Meta-Analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

This meta-analysis aimed to compare percutaneous (PPS) versus open pedicle screw (OPS) fixation for treatment of thoracic and lumbar spondylodiscitis.

SUMMARY OF BACKGROUND DATA

Pyogenic spondylodiscitis of the thoracic and lumbar spine can produce instability, deformity, and/or neurological compromise. When medical treatment is unsuccessful, surgical treatment is indicated, with the conventional open approach the usual standard of care. However, percutaneous techniques can be advantageous in medically vulnerable patients.

MATERIALS AND METHODS

A literature search was performed using the PubMed, Web of Science, and Scopus databases, looking for comparative articles on pyogenic spondylodiscitis requiring surgical stabilization with pedicle screws. This systematic review is reported according to PRISMA guidelines.

RESULTS

From 215 articles initially identified, 7 retrospective studies were analyzed, encapsulating an overall sample of 722 patients: 405 male (56.1%) and 317 female (43.9%). The treatment modality was PPS fixation in 342 patients (47.4%) and OPS fixation in 380 (52.6%). For PPS, operating time was 29.75 minutes ( P <0.0001), blood loss 390.18 mL ( P <0.00001), postoperative pain 1.54 points ( P <0.00001), and length of stay 4.49 days ( P =0.001) less than with OPS fixation, and wound infection 7.2% ( P =0.003) less frequent. No difference in screw misplacement ( P =0.94) or loosening ( P =0.33) rates was observed.

CONCLUSION

Employing PPS fixation to treat pyogenic spondylodiscitis of the thoracic and lumbar spine is associated with significantly reduced operating time, blood loss, postoperative pain, length of stay, and rates of wound infection than OPS fixation, with no difference between the 2 treatments in rates of screw misplacement or screw loosening.

Treatment of Thoracolumbar Pyogenic Spondylitis with Minimally Invasive Posterior Fixation without Anterior Lesion Debridement or Bone Grafting: A Multicenter Case Study

The usefulness of minimally invasive posterior fixation without debridement and autogenous bone grafting remains unknown. This multicenter case series aimed to determine the clinical outcomes and limitations of this method for thoracolumbar pyogenic spondylitis. Patients with thoracolumbar pyogenic spondylitis treated with minimally invasive posterior fixation alone were retrospectively evaluated at nine affiliated hospitals since April 2016. The study included 31 patients (23 men and 8 women; mean age, 73.3 years). The clinical course of the patients and requirement of additional anterior surgery constituted the study outcomes. The postoperative numerical rating scale score for lower back pain was significantly smaller than the preoperative score (5.8 vs. 3.6, p = 0.0055). The preoperative local kyphosis angle was 6.7°, which was corrected to 0.1° after surgery and 3.7° at the final follow-up visit. Owing to failed infection control, three patients (9.6%) required additional anterior debridement and autogenous bone grafting. Thus, in this multicenter case series, a large proportion of patients with thoracolumbar pyogenic spondylitis could be treated with minimally invasive posterior fixation alone, thereby indicating it as a treatment option for pyogenic spondylitis.

Biomechanical evaluation of position and bicortical fixation of anterior lateral vertebral screws in a porcine model

Although an anterior approach with anterior lateral screw fixation has been developed for stabilizing the thoracolumbar spine clinically, screw loosening still occurs. In this novel in vitro study, we attempted to elucidate the optimal screw position in the lateral lumbar vertebra and the effect of bicortical fixation. A total of 72 fresh-frozen lumbar vertebrae from L1-6 were harvested from 12 mature pigs and randomly assigned to two modalities: bicortical fixation (n = 36) and unicortical fixation (n = 36). Six groups of screw positions in the lateral vertebral body in each modality were designated as central-anterior, central-middle, central-posterior, lower-anterior, lower-middle, and lower- posterior; 6 specimens were used in each group. The correlations between screw fixation modalities, screw positions and axial pullout strength were analyzed. An appropriate screw trajectory and insertional depth were confirmed using axial and sagittal X-ray imaging prior to pullout testing. In both bicortical and unicortical fixation modalities, the screw pullout force was significantly higher in the posterior or middle position than in the anterior position (p < 0.05), and there was no significant differences between the central and lower positions. The maximal pullout forces from the same screw positions in unicortical fixation modalities were all significantly lower, decreases that ranged from 32.7 to 74%, than those in bicortical fixation modalities. Our study using porcine vertebrae showed that screws in the middle or posterior position of the lateral vertebral body had a higher pullout performance than those in the anterior position. Posteriorly positioned lateral vertebral screws with unicortical fixation provided better stability than anteriorly positioned screws with bicortical fixation.

Biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation for lumbar brucellosis spondylitis

Objective

This study aims to investigate the effectiveness and feasibility of biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation for lumbar brucellosis spondylitis (LBS).

Methods

The data of 13 patients with LBS were retrospectively analyzed, who underwent biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation from May 2020 to June 2022. The patients' clinical data, the duration of operation, the estimated blood loss (including postoperative drainage), and complications were recorded. Clinical outcomes include serum agglutination test (SAT) measures Brucella antibody titer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the visual analog scale (VAS) scores of low back and leg, Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), American Spinal Injury Association neurological classification, and lordotic angle were analyzed. All patients were assessed using the modified Macnab criteria at the final follow-up. The intervertebral bone graft fusion was assessed using the Bridwell grading criteria.

Results

The mean operation duration was 177.31 ± 19.54 min, and the estimated blood loss was 176.15 ± 43.79 ml (including postoperative drainage was 41.15 ± 10.44 ml). The mean follow-up period was 13.92 ± 1.5 months. SAT showed that the antibody titers of 13 patients were normal 3 months after the operation and at the final follow-up. ESR and CRP levels returned to normal by the end of the 3-month follow-up. VAS scores of low back and leg, JOA score, and ODI significantly improved after the operation throughout the follow-up period (P < 0.05). Based on the modified Macnab criteria, 92.3% showed excellent to good outcomes. One patient had only a percutaneous screw internal fixation on the decompression side due to severe osteoporosis. One case suffered a superficial incision infection postoperatively that healed with dressing change and effective antibiotic treatment. Bony fusion was obtained in all patients at the last follow-up, including 12 cases with grade I and 1 case with grade II, with a fusion rate of 92.31%.

Conclusion

Biportal endoscopic decompression, debridement, and interbody fusion, combined with percutaneous screw fixation is an effective, safe, and viable surgical procedure for the treatment of LBS.

Surgical Treatment Strategies for Pyogenic Spondylodiscitis of the Thoracolumbar Spine

BACKGROUND

Despite advances, the morbidity and mortality rates of patients with spondylodiscitis remains high, with an increasing incidence worldwide. Although conservative therapy has progressed, several cases require surgical intervention. However, the indication and opportunities for surgical treatment are still disputable.

METHODS

In a joint consensus, the members of the 'Spondylodiscitis' working group of the Spine Section of the German Society for Orthopaedics and Trauma Surgery considered current literature, particularly the newly published S2k guideline of the AWMF, and examined the surgical indications and treatment strategies for thoracolumbar spondylodiscitis.

RESULTS

Surgical intervention for spondylodiscitis is only required in a small percentage of patients. In studies comparing conservative and surgical therapies, most patients benefitted from surgery, regardless of the surgical technique selected. Presently, the standard procedure is a combined dorsoventral approach, in which a monolateral attempt should always be made. The choice of material (PEEK, titanium) for ventral support does not influence the clinical result.

Treatment of Refractory Multilevel Thoracic Spondylodiscitis Using Ultra-Minimally Invasive Endoscopic Approach for Debridement and Drainage: A Technical Note, Intraoperative Video, and Literature Review

OBJECTIVE/BACKGROUND

Spondylodiscitis is an infection of the spinal column which can result in pain, deformity, instability, and/or neurologic deficits. When surgical treatment is required for thoracic spondylodiscitis, invasive open approaches are often utilized due to the ventral location of the pathology.

METHODS

We describe the use of a spinal endoscope to perform drainage and debridement of infected tissue through a transforaminal/intradiscal approach in a patient with multilevel thoracic spondylodiscitis refractory to antibiotic therapy. Illustrative videos are provided, as well as a review of the relevant literature.

RESULTS

A total of 188 patients were included in the systematic review. The mean positive reported culture rate was 76% (117/154 patients). The mean preoperative visual analog scale score was 6.8 (n = 114), and the mean postoperative visual analog scale score was 1.8 at 1 week postoperatively (n = 56) and 1.01 at the final follow-up (n = 114). The most common surgical approach was transforaminal/intradiscal (103/188 patients, 54.8%). The mean reoperation rate was 9.1%. The mean complication rate was 5.25%, with complications including increased transient radicular pain, infection, hardware failure, and new unspecified neurological deficits.

CONCLUSION

This case and those highlighted in our literature review demonstrate that endoscopic treatment for thoracic spondylodiscitis is a viable alternative to traditional open surgery in many cases.

Unexpectedly rapid decrease in the size of a spinal epidural abscess after percutaneous posterior pedicle screw fixation without decompression surgery: a case report

INTRODUCTION

Spondylodiscitis accompanying spinal epidural abscess is often treated with decompression surgery when there are neurological symptoms. We report a case of spondylodiscitis accompanying spinal epidural abscess with severe lower extremity pain that was successfully treated with percutaneous posterior pedicle screw fixation without decompression surgery.

CASE PRESENTATION

A 53-year-old man was admitted to our hospital with severe low back pain (LBP), lower extremity pain and numbness, and fever. Lumbar magnetic resonance imaging (MRI) revealed spondylodiscitis at L2-L3 and a small epidural abscess located ventrally in the spinal canal. Initially, the patient was treated conservatively with empirical antibiotics. However, the lower extremity symptoms worsened and the epidural abscess expanded cranially to the T12 level. Percutaneous pedicle screw fixation without decompression was performed thirty-three days after admission. Postoperatively, the LBP and lower extremity pain dramatically improved. A postoperative MRI performed one week post-operatively showed an unexpectedly rapid decrease in the size of the epidural abscess, although no decompression surgery was performed. Two months after surgery, the epidural abscess completely disappeared. At the final follow-up (five years postoperatively), no recurrence of epidural abscess was observed, and the patient had no symptoms or disturbance of activities of daily living.

DISCUSSION

This surgical strategy should be carefully selected for patients with spondylodiscitis with accompanying spinal epidural abscess who have lower extremity symptoms. The stabilising effect of pedicle screw fixation may be advantageous for controlling spinal infections. Percutaneous posterior pedicle screw fixation without decompression is an optional treatment for spondylodiscitis accompanying spinal epidural abscess.

Minimally Invasive Spine Stabilization for Pyogenic Spondylodiscitis: A 23-Case Series and Review of Literature

Background and Objectives: The incidence of pyogenic spondylodiscitis has been increasing due to the aging of the population. Although surgical treatment is performed for refractory pyogenic spondylodiscitis, surgical invasiveness should be considered. Recent minimally invasive spine stabilization (MISt) using percutaneous pedicle screw (PPS) can be a less invasive approach. The purpose of this study was to evaluate surgical results and clinical outcomes after MISt with PPS for pyogenic spondylodiscitis. Materials and Methods: Clinical data of patients who underwent MISt with PPS for pyogenic spondylitis were analyzed. Results: Twenty-three patients (18 male, 5 female, mean age 67.0 years) were retrospectively enrolled. The mean follow-up period was 15.9 months after surgery. The causative organism was identified in 16 cases (69.6%). A mean number of fixed vertebrae was 4.1, and the estimated blood loss was 145.0 mL. MISt with PPS was successfully performed in 19 of 23 patients (82.6%). Four cases (17.4%) required additional anterior debridement and autologous iliac bone graft placement. CRP levels had become negative at an average of 28.4 days after surgery. There was no major perioperative complication and no screw or rod breakages during follow-up. Conclusions: MISt with PPS would be a less invasive approach for pyogenic spondylodiscitis in elderly or immunocompromised patients.

A New Treatment Algorithm That Incorporates Minimally Invasive Surgery for Pyogenic Spondylodiscitis in the Thoracic and Lumbar Spines: The Results of Its Clinical Application to a Series of 34 Patients

Background and Objectives: Spinal minimally invasive surgery (MIS) experts at the university hospital worked as a team to develop a new treatment algorithm for pyogenic spondylodiscitis in lumbar and thoracic spines. They modified a flow chart introduced for this condition in a pre-MIS era to incorporate MIS techniques based on their extensive experiences accumulated over the years, both in MIS for degenerative lumbar diseases and in the treatment of spine infections. The MIS procedures incorporated in this algorithm consisted of percutaneous pedicle screw (PPS)–rod fixation and transpsoas lateral lumbar interbody fusion (LLIF). The current study analyzed a series of 34 patients treated with prospective selection of the methods according to this new algorithm. Materials and Methods: The algorithm first divided the patients into those who had escaped complicated disease conditions, such as neurologic impairment, extensive bone destruction, and the need to be mobilized without delay (Group 1) (19), and those with complicated pyogenic spondylodiscitis (Group 2) (15). Group 1 had image-guided needle biopsy followed by conservative treatment alone with antibiotics and a spinal brace (12) (Group 1-A) or a subsequent addition of non-fused PPS–rod fixation (7) (Group 1-B). Group 2 underwent an immediate single-stage MIS with non-fused PPS–rod fixation followed by posterior exposure for decompression and debridement through a small midline incision (12) (Group 2-A) or an additional LLIF procedure after an interval of 3 weeks (3) (Group 2-B). Results: All patients, except four, who either died from causes unrelated to the spondylodiscitis (2) or became lost to follow up (2), were cured of infection with normalized CRP at an average follow up of 606 days (105–1522 days). A solid interbody fusion occurred at the affected vertebrae in 15 patients (50%). Of the patients in Group 2, all but two regained a nearly normal function. Despite concerns about non-fused PPS–rod instrumentation, only seven patients (21%) required implant removal or replacement. Conclusions: Non-fused PPS–rod placements into infection-free vertebrae alone or in combination with posterior debridement through a small incision worked effectively in providing local stabilization without contamination of the metal implant from the infected tissue. MIS LLIF allowed for direct access to the infected focus for bone grafting in cases of extensive vertebral body destruction.

Outcome of one-stage percutaneous endoscopic debridement and lavage combined with percutaneous pedicle screw fixation for lumbar pyogenic spondylodiscitis

BACKGROUND

This study assessed the therapeutic effect of one-stage percutaneous endoscopic debridement and lavage (PEDL) combined with percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar pyogenic spondylodiscitis.

METHODS

From March 2017 to October 2019, 51 patients diagnosed with pyogenic spondylodiscitis underwent PPSF followed by PEDL in our department. Biopsy specimens were examined for microorganisms and evaluated histopathologically. Clinical outcomes were assessed by physical examination, routine serological testing, visual analogue scale (VAS), Oswestry Disability Index (ODI) and imaging studies.

RESULTS

Of the enrolled patients, the operation time ranged from 90 min to 114 min every level with an average of 102 min, and the average drainage time ranged from 6 days to 10 days with an average of 7.4 days. All patients who complained of lower back pain symptoms were more relieved than before surgery. Causative pathogens were identified in 20 of 51 biopsy specimens; Staphylococcus aureus was the most prevalent. However, there were eight patients with postoperative complications. The mean follow-up was 25.0 ± 3.8 (range: 20-32) months. Inflammatory markers showed that infection was controlled. The VAS and ODI improved significantly. At the last follow-up, magnetic resonance imaging showed that the infected lesions had disappeared.

CONCLUSION

PEDL supplementing PPSF may be useful for patients with single-level lumbar pyogenic spondylodiscitis, as it is minimally invasive, especially for patients who cannot undergo conventional open surgery due to poor health or advanced age.

Endoscopic treatment of spondylodiscitis: systematic review

BACKGROUND

Spondylodiscitis is a severe condition where standalone antibiotic therapy resolves most cases. In refractory infections, open surgery may aid with infection debulking. However, significant morbidity can occur. Nowadays, endoscopic approaches are emerging as an alternative. However, until now, only small-scale studies exist. Being so, we carried the first systematic review on spondylodiscitis endoscopic debridement indications, technique details, and outcomes.

METHODS

Search for all English written original studies approaching the spondylodiscitis endoscopic treatment was performed using PubMed and EBSCO host. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a pre-specified protocol was registered at PROSPERO (CRD42020183657).

RESULTS

Fourteen studies involving 342 participants were included for analysis. Data overall quality was fair. Indications for the endoscopic approach were poorly defined. The most consensual indication was refractory infection to conservative treatment. Spinal instability or neurological deficits were common exclusion criteria. All authors described similar techniques, and despite the frequent severe co-morbidities, procedure morbidity was low. Re-interventions were common. Microorganism identification varied from 54.2 to 90.4%. Treatment failure among studies ranged from 0 to 33%. Pain, functional status, and neurological deficits had satisfactory improvement after procedures.

CONCLUSIONS

The endoscopic debridement of spondylodiscitis seems to be an effective and safe approach for refractory spondylodiscitis. A novel approach with initial endoscopic infection debulking and antibiotic therapy could improve the success of spondylodiscitis treatment.

Pyogenic and Non-Pyogenic Spinal Infections: Diagnosis and Treatment

Spinal infection (SI) is an infection of vertebral bodies, intervening disc, and/or adjoining para-spinal tissue. It represents less than 10 % of all skeletal infections. There are numerous factors that predispose to developing a SI. Due to the low specificity of signs, delayed diagnosis is common. Hence, SI may be associated with poor outcomes. Diagnosis of SI must be supported by clinicopathological and radiological findings. MRI is a reliable modality of choice. Treatment options vary according to the site of the infection, disease progression, neurology, presence of instability, and general condition of the subject. Conservative treatment (orthosis/ bed-rest + antibiotics) is recommended during the early course with no/ lesser degree of neurological involvement and to medically unfit patients. Nevertheless, when conservative measures alone fail, surgical interventions must be considered. The use of concomitant antimicrobial drugs intravenously during initial duration followed by oral administration is a necessity. Controversies exist regarding the optimal duration of antimicrobial therapy, yet never given less than six weeks. Heterogeneity in clinical picture and associated co-morbidities with a range of treatment modalities are available; however, a common applicable guideline for SI does not exist. Managing SI must be tailored on a case-to-case basis.

Minimally invasive posterior pedicle screw fixation versus open instrumentation in patients with thoracolumbar spondylodiscitis

BACKGROUND

Due to the aging society, the incidence of pyogenic spondylodiscitis is still rising. Although surgical treatment for spondylodiscitis in general is increasingly accepted, an optimal surgical strategy for treatment of pyogenic spinal infection has not yet been established. The aim of this study was to investigate the suitability of percutaneous posterior pedicle screw fixation for surgical treatment in patients with spondylodiscitis of the thoracolumbar spine.

METHODS

We conducted a retrospective review of a consecutive cohort of patients undergoing surgical treatment for spondylodiscitis of the thoracolumbar spine between January 2017 and December 2019. We assessed intraoperative and clinical data, comparing for the classic open and the percutaneous approach. In total, we analyzed 125 cases (39 female, 86 male). The mean age was 69.49 years ± 12.63 years.

RESULTS

Forty-seven (37.6%) patients were operated on by a percutaneous approach for pedicle screw fixation, and 78 (62.4%) received open surgery. There was no significant difference in the mean age of patients between both groups (p= 0.57). The time of surgery for percutaneous fixation was statistically significantly shorter (p= 0.03). Furthermore, the estimated intraoperative blood loss was significantly lower in the minimally invasive group (p < 0.001). No significant difference could be observed regarding the recurrence rate of spondylodiscitis and the occurrence of surgical site infections (p= 0.2 and 0.5, respectively).

CONCLUSION

Percutaneous posterior pedicle screw fixation appears to be a feasible option for the surgical treatment of a selected patient group with spondylodiscitis of the thoracic and lumbar spine.

Hybrid Minimally Invasive Technique for Treatment of Thoracolumbar Spondylodiscitis and Vertebral Osteomyelitis

OBJECTIVE

Spondylodiscitis and vertebral osteomyelitis cause significant morbidity and mortality, and typically occur in patients with multiple comorbidities. The use of minimally invasive spinal surgery in the previous decade has offered the advantages of reduced intraoperative blood loss and postoperative pain for patients. In the present report, we have described our experience with using a hybrid minimally invasive (HMI) technique (combining percutaneous fixation with a mini-open approach for decompression and debridement) for the treatment of thoracolumbar spondylodiscitis, reporting the patient demographics, intraoperative measures, and 12-month outcomes.

METHODS

The data from patients presenting to a tertiary referral neurosurgical center with thoracolumbar spondylodiscitis and osteomyelitis who had undergone HMI from 2016 to 2018 were retrospectively evaluated. Patient demographics, intraoperative factors, estimated blood loss, and immediate postoperative complications were recorded. The patient outcomes were evaluated using EuroQOL 5-dimension questionnaire and visual analog scale in the immediate postoperative period and at 12 months postoperatively.

RESULTS

A total of 13 patients were included in the present study, 12 with spontaneous infection and 1 with infection secondary to recent microdiscectomy at another institution. All the patients had systemic comorbidities with an American Society of Anesthesiologists class of ≥2. Of the 13 patients, 11 had pyogenic infections and 2 had spinal tuberculosis. The mean estimated blood loss was 546.2 mL. The mean time for patients to sit out of bed was 2.2 days, and the mean time to start mobilizing was 4.5 days. The EuroQOL 5-dimension questionnaire scores showed improvement in all modalities at 12 months postoperatively.

CONCLUSIONS

In our cohort, HMI was a safe and effective treatment of thoracolumbar spondylodiscitis, with the potential benefits of reduced blood loss, operative duration, and postoperative pain.