Posterior instrumentation, anterior column reconstruction with single posterior approach for treatment of pyogenic osteomyelitis of thoracic and lumbar spine

Multidisciplinary management of thoracic esophageal fistula secondary to traumatic upper thoracic fracture (T3-4) with associated discitis/osteomyelitis and spinal epidural abscess: illustrative case

BACKGROUND

An esophageal fistula secondary to a traumatic upper thoracic (T3-4) fracture with resultant thoracic discitis/osteomyelitis and an epidural abscess with neurological compromise is a rare clinical entity. Early diagnosis is critical for an optimal clinical outcome avoiding grave and progressive spinal dissemination with structural instability and neurological deterioration.

OBSERVATIONS

The following case, not clearly described previously in the literature, highlights the clinical course and multidisciplinary approach to management including a single-stage posterior cervicothoracic (C3-T6) decompression with vertebral reconstruction with an expandable interbody cage (T2-4) and posterior cervicothoracic fusion and instrumentation (C3-T6), followed by direct esophageal fistula closure with AlloDerm and a vascularized latissimus dorsi muscle flap.

LESSONS

Early diagnosis and the potential treatment of a posttraumatic esophageal fistula requires a multidisciplinary approach.

The Diagnostic Value of Blood Next-Generation Sequencing in Early Surgical Site Infection After Spine Surgery

Objective

To determine the diagnostic value of blood next-generation sequencing (NGS) in early surgical site infection after spine surgery. Because the blood is sterile in healthy individuals, it is expected that blood NGS is both sensitive and specific for the detection of infection.

Methods

A total of 28 patients with definitive spinal surgical site infections and controls (n=30) were retrospectively included. The postoperative results of NGS and culture on different samples, such as blood and drainage fluid, were obtained and compared to evaluate the diagnostic value of blood NGS. The diagnostic value parameters (sensitivity, specificity, etc.) were calculated.

Results

Among the four bacteriological exam methods, blood NGS was both sensitive and specific for the determination of infection after spine surgery. The sensitivities of blood and drainage fluid NGS were similar (0.82 vs 0.89, P=0.617). However, the specificities of the two assessments differed, which were 0.97 for blood NGS and 0.40 for drainage fluid NGS (P<0.001). The sensitivities of bacterial culture were lower than those of NGS (blood: 0.82 vs 0.25, P<0.001; drainage fluid: 0.89 vs 0.61, P<0.001), regardless of the sample type. However, the specificities of bacterial culture were equal to or higher than those of NGS (blood: 0.97 vs 0.97, P=1.000; drainage fluid: 0.40 vs 0.80, P=0.002).

Conclusion

This article emphasizes the superiority of blood NGS in infection detection and bacterial determination in patients undergoing spine surgery. Compared with traditional drainage fluid bacterial culture and NGS, blood NGS was more sensitive and specific, and its extensive application could be expected.

Management of vertebral osteomyelitis in adults

Vertebral osteomyelitis is a condition that predominantly affects older men with chronic comorbidities, such as diabetes, renal and hepatic failure, or immunosuppression. Symptoms develop insidiously and a high index of suspicion is required to diagnose the condition; this is achieved through serological testing and imaging. The mainstay of treatment is long-term antibiotic therapy, lasting a minimum of 6 weeks; however, surgical debridement with stabilisation is required when conservative treatment is proving ineffective and infection progresses. It is critically important that sufficient treatment is provided for those experiencing vertebral osteomyelitis, as not doing so could lead to severe neurological compromise and death.

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.

A prospective study comparing three different all-posterior surgical techniques in the management of thoracolumbar spinal tuberculosis

Background

Posterior only surgery has been widely performed in the treatment of thoracic and lumbar spinal tuberculosis. Surgical options include debridement with posterior instrumentation only or combined with anterior reconstruction. The aim of this study is to investigate and compare the clinical, functional and radiological outcomes using a single-stage posterior only surgery in thoracolumbar spinal tuberculosis by three different surgical techniques.

Methods

Patients undergoing posterior only surgery for thoracic and lumbar spinal tuberculosis were followed up prospectively and included. Three different procedures, Group-A: Posterior instrumentation with anterior cage reconstruction (n = 49), Group-B: Posterior instrumentation and anterior autologous bone-grafting (n = 21) and Group-C: Posterior column shortening without anterior-reconstruction (n = 52) were compared for kyphosis correction achieved, kyphosis at final follow-up and degree of correction lost. Neurological assessment was done using ASIA impairment Scale(AIS) grades. Functional assessment was done using Visual analogue score (VAS), Modified McNab criteria and NASS satisfaction score.

Results

A total of 122 patients were included in the study, Group-A (49), Group-B (21) and Group-C (52). Radiological correction of kyphotic deformity in anterior reconstruction, Group-A (20.17 ± 9.25⁰) was higher than 13.97⁰ ± 6.06⁰ and 14.27⁰ ± 6.47⁰ achieved in Groups B and C respectively. There was no significant difference in correction lost amongst the three groups (p-value, 0.76). Surgical duration, blood loss and hospital stay were significantly higher in the anterior reconstruction group (p-value, 0.001). Similarly, no significant difference was noted between the three groups in neurological and functional outcomes at 2 years.

Conclusion

Posterior only approach is eminently satisfactory for treating Thoracolumbar Spinal Tuberculosis (STB). All three groups had similar functional and neurological outcomes. However there was a better correction of deformity in patients with anterior cage reconstruction.

Posterior-only debridement, bone fusion, single-segment versus short-segment instrumentation for mono-segmental lumbar or lumbosacral pyogenic vertebral osteomyelitis: minimum five year follow-up outcomes

Background

Pyogenic vertebral osteomyelitis (PVO), which is a potentially life-threatening condition and is associated with significant morbidity and mortality, is a cause of back pain that can lead to neurologic deficits if not diagnosed in time and effectively treated. The objective of this study is to compare the efficacy of posterior single-segment and short-segment fixation combined with one-stage posterior debridement and fusion for the treatment of mono-segmental lumbar or lumbosacral PVO.

Methods

Charts of all patients with mono-segmental lumbar or lumbosacral PVO were treated by single-stage posterior debridement, bone graft fusion, and pedicle screw fixation from April 2012 to January 2016. All patients were divided into two groups: sinlge-segment fixation (Group A, n = 31) and short-segment fixation (Group B, n = 36). These patients were followed up for a minimum of five years. The clinical efficacy was evaluated and compared on average operation time, blood loss, visual analog scale (VAS), erythrocyte sedimentation rate (ESR), C-Reactive protein (CRP), neurological function recovery and local lordotic angle.

Results

All 67 patients were completely cured during the follow-up. All patients had significant improvement of neurological condition and pain relief at the final follow-up. The VAS was 7.1 ± 0.7 in group A and 7.2 ± 0.6 in group B pre-operatively, which decreased to 2.1 ± 0.6 and 2.0 ± 0.7, respectively, at three months after surgery, then reduced to 0.4 ± 0.5 and 0.5 ± 0.5, respectively, at the final follow-up. ESR, CRP returned to normal limits in all patients 3 months after surgery. The mean blood loss and operation time in group A were less than that in group B (P < 0.05). The local lordotic angle in group A was increased from preoperative − 1.7 ± 7.9° to postoperative 5.8 ± 7.1°, with angle loss of 1.5 ± 0.8° at the final follow-up, respectively (P < 0.05). The local lordotic angle in group B was increased from preoperative − 1.6 ± 7.8° to postoperative 13.5 ± 6.2°, with angle loss of 1.3 ± 0.8° at the final follow-up, respectively (P < 0.05). In the mean postoperative local lordotic angle, there was significant difference between the two groups at the time of immediate postoperative period or the final follow-up (P < 0.05).

Conclusion

Posterior-only debridement, interbody graft using titanium mesh cage, posterior single-segment instrumentation and fusion represent a safe and effective treatment option for selected patients with mono-segmental lumbar and lumbosacral PVO. This approach may preserve more lumbar normal motor units with less blood loss and operation time when compared with that of short-segment fixation. But short-segment fixation was superior to the single-segment fixation in the correction of kyphosis.

Total en bloc spondylectomy in the treatment of postoperative chronic osteomyelitis: a case report

BACKGROUND

Infection of the spine after surgical procedures is one of the most dreaded complications of spinal fusion surgery. Treatment goals are to eradicate the necrotic and infected tissue and to obtain a correct spinal profile. Traditionally many authors have recommended the posterolateral or double approach, anterior and posterior. Total en bloc spondylectomy is a surgical procedure traditionally used to treat primary and metastatic tumors. The use of this surgical procedure in treatment of chronic vertebral osteomyelitis is not clearly defined in literature.

CASE DESCRIPTION

This case involved a 66-year-old female patient with a history of T9-S1 instrumentation after several surgeries, who developed chronic osteomyelitis of T8-T9 with extensive destruction of the vertebral body and severe thoracic kyphosis. After targeted antibiotic therapy, total en bloc spondylectomy of T8-T9 was performed according to the Tomita technique. Necrotic and infected tissues were removed proceeding as if it were chronic osteomyelitis of long bones and performing en bloc resection with clear margins, that is, applying the criteria of oncological surgery to this chronic infection. After resection, the sagittal plane is reconstructed in the affected segment, restoring the normal distance between the two healthy vertebrae and the mechanical stability of the spine.

CONCLUSIONS

Total en bloc spondylectomy in the treatment of extensive infectious lesions with a mechanical component allows performing en bloc resection of infected and necrotic tissue along with biological and mechanical reconstruction. In our case, the complete resection of the infected bone and soft tissues achieved good outcome without complications. We propose total en bloc spondylectomy as a reasonable treatment option in complicated spondylodiscitis progressing to extensive chronic osteomyelitis and compromising spinal stability due to a significant loss of bone material.

Radiographic Features Associated With Increased Surgical Invasiveness in Pyogenic Vertebral Column Osteomyelitis

STUDY DESIGN

Single center retrospective cohort study.

OBJECTIVES

Assess the association between well-known radiographic features for spinal instability from the Spinal Instability in Neoplasia Score (SINS) and surgical invasiveness in treating vertebral column osteomyelitis (VCO). This will potentially help surgeons in surgical planning and aid in developing a pathology specific score.

METHODS

Patients with VCO were identified from hospital coding. On preoperative computed tomography radiographic features, including spinal alignment, vertebral body collapse, location, type of bone lesion, and posterolateral involvement were assessed and scored 0 (stable) to 15 (highly unstable). Surgical invasiveness was graded as 0 = no surgery, 1 = decompression alone, 2 = shortening or posterior stabilization, or 3 = anterior column reconstruction.

RESULTS

A total of 41 patients were included. The mean age of the cohort was 63.3 years (SD 12.0) with male comprising 78%. The mean total radiographic score for the nonsurgical group was 6.39 (3.14) and for the surgical group 10.38 (3.06), P < .001. Spinal alignment, vertebral body collapse, type of bone lesion, and posterolateral involvement correlated with surgical invasiveness (all Ps < .05). Subgroup comparison following analysis of variance showed that only spinal alignment was significantly different between groups 2 and 3.

CONCLUSIONS

Our findings show correlation of the radiographic components of the SINS with surgical invasiveness in management of pyogenic VCO-these findings should aid development of an "instability score" in pyogenic VCO. While most radiographic features assessed correlated with surgical invasiveness spinal alignment appears to be the key feature in determining the need for more invasive surgery.

Skipping Pedicle Screw Insertion Into Infected Vertebra is a Risk Factor for Revision Surgery for Pyogenic Spondylitis in the Lower Thoracic and Lumbar Spine

BACKGROUND

Surgical intervention for pyogenic spondylitis is indicated when conservative treatment fails and biomechanical instability persists. Whether to insert pedicle screws into all vertebrae, including the most erosive vertebrae, or whether to skip 1 vertebra in pedicle screw insertion remains controversial.

METHODS

A single-institution retrospective cohort study was conducted in consecutive patients with pyogenic spondylitis in the lower thoracic and lumbar spine (T9-S1) between January 2008 and December 2016. The patients were treated with interbody fusion plus posterior stabilization using pedicle screws and were divided into 2 groups as follows: (1) patients in whom 1 vertebra, usually the most erosive, was skipped in pedicle screw insertion (Group Skipping) and (2) pedicle screw insertion into all vertebrae (Group All). Patients' operation data were evaluated, and clinical outcomes were compared between the 2 groups. There were no significant differences between the 2 groups in terms of age, sex, past histories, blood loss, operation time, the presence of abscesses, or operative approach.

RESULTS

The length of fixation was greater by 1 vertebral level in the Group Skipping than in the Group All, and the rate of revision surgery for pseudarthrosis was higher in the Group Skipping than in the Group All (P = .02). There was no statistically significant difference between the 2 groups in terms of the mean segmental lordotic angle or Barthel Index.

CONCLUSIONS

Skipping pedicle screw insertion for pyogenic spondylitis in posterior fixation led to an increased number of fixed vertebrae and may be a risk factor for revision surgery for pseudarthrosis.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

The insertion of short pedicle screws at the infected vertebra can prevent early treatment failure and increase the biomechanical stability of construct.

Effects of pre-contoured and in situ contoured rods on the mechanical strength and durability of posterior cervical instrumentation: a finite-element analysis and scanning electron microscopy investigation

STUDY DESIGN

Finite-element analysis.

OBJECTIVES

Intraoperative contouring of rods is a common procedure for spine surgeons to match the native curvature of the spine, but it may lead to premature weakening of the rod. This study investigated the effect of different bending methods on rod fatigue performance. Rod failure in the cervical spine is of clinical concern, particularly when spanning the cervicothoracic region and when considering corrective osteotomies for deformity correction and global spinal alignment.

METHODS

Finite-element models were developed to simulate rod bending (3.5 mm D, 40 mm L) to achieve a 23° angle with 3 different bending methods: French single, multiple bending, and in situ bending. Simulations were conducted in 4 steps: rod bending, rod spring back, residual stress relaxation, and F1717 mechanical test simulation.

RESULTS

French single bending resulted in the highest residual stress concentrations for both titanium (TiAlV) and cobalt chrome (CoCr) at 783 MPa and 507 MPa, respectively. During F1717 test simulation, the French single bent rod had its highest tensile stress in the middle, with 917 MPa and 623 MPa, respectively, for TiAlV and CoCr, compared to in situ (580 MPa and 586 MPa for TiAlV and CoCr) and the French multiple bent rod (765 MPa and 619 MPa for TiAlV and CoCr). The computational model found that CoCr rods made the construct least prone to deformation.

CONCLUSIONS

French single bend with TiAlV rods put the construct at highest risk of failure. CoCr rods led to minimal physical changes in microstructure while showing evidence of flattening.

Osteomyelitis-Discitis at the Thoracolumbar Junction and the Development of Postinfectious Spinal Deformity: A Surgical Case Series

BACKGROUND

Progressive spinal deformity and neural compromise are the main indications for surgical management of vertebral osteomyelitis-discitis. However, when such pathology presents at the thoracolumbar (TL) junction, it remains unclear what the appropriate intervention is. The therapeutic dilemmas of decompression with or without instrumented fusion, the need for circumferential decompression and reconstruction, as well as the prognostic factors for progression of kyphosis, all remained ill-defined in the literature. The objective of this study is to evaluate risk factors for instrumentation at TL junction in spinal osteomyelitis-discitis.

METHODS

A review of patients at a single center with osteomyelitis-discitis at the TL junction between 2014 and 2018 was performed. Patients were 18 years or older with infectious pathologies at T10 to L2.

RESULTS

Sixteen patients were included. Indication for instrumentation included progression of kyphosis following prior laminectomy/medical management. Of the 16 patients, 4 patients received laminectomy at initial treatment versus 12 patients receiving medical management alone. All 4 patients receiving laminectomy experienced progressive kyphosis requiring revision with instrumented fusion versus only 4 of 12 of the medically managed. Laminectomy, epidural compression, and vertebral body collapse were significant risk factors for kyphosis progression requiring instrumentation. The average time to surgical intervention for the indication of progressive kyphosis was 2.6 months after prior laminectomy and 6 months after initiation of medical management.

CONCLUSIONS

Given the proclivity for kyphotic deformity at the TL junction, patients may benefit from long segment instrumentation in addition to decompression at the initial surgery. Laminectomy alone may hasten kyphosis progression.

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.

Polyetheretherketone (PEEK) cages for anterior column reconstruction in pyogenic vertebral osteomyelitis

The objective of study was to evaluate a case series of patients in whom polyetheretherketone (PEEK) cages were used for anterior column reconstruction in vertebral osteomyelitis. Fifteen patients underwent clinical and radiological evaluation with average follow-up of 26 months. Parameters assessed were time of surgery, blood loss, segmental kyphosis or lordosis angle, time to solid bony fusion, ambulatory status, and functional outcome. Mean time of surgery was 150 min with mean blood loss of 530 ml. One patient died in early postoperative period. All patients without preoperative neurologic deficit were walking unaided first day postoperatively. Solid bony fusion was demonstrated in 14 patients, on average 7.1 months postoperatively. Functional outcome at the latest follow-up was excellent, good, or fair in 86%. Two failures with recurrent infection were treated with PEEK cage removal and reinstrumentation. High success rate could be expected when PEEK cages are used for anterior column support in pyogenic vertebral osteomyelitis.

Anterior Cervical Debridement and Fusion for Cervical Pyogenic Spondylodiscitis: Use of Anterior Cervical Plating or Not?

STUDY DESIGN

Retrospective multicenter case series.

OBJECTIVE

We sought to evaluate the safety and efficacy of anterior cervical plating in anterior cervical debridement and fusion (ACDF) for patients with cervical pyogenic spondylodiscitis (CPS).

SUMMARY OF BACKGROUND DATA

Due to concerns about bacterial seeding on the foreign material after instrumentations in pyogenic infections, the safety and efficacy of anterior cervical plating for CPS are still undetermined and controversial. Little information is available about the safety and efficacy of anterior cervical plating to manage CPS.

METHODS

Twenty-three patients who underwent ACDF with (n = 12) or without (n = 11) plating for CPS were included. The mean age was 62.6 years. Medical records were reviewed and radiological parameters including segmental height, segmental angle, C2-C7 angle, and fusion status were analyzed. The mean follow-up period after surgery was 21.3 months.

RESULTS

After ACDF with plating, segmental height, segmental angle, and C2-C7 angle were significantly improved compared with preoperative conditions and remained well-maintained at the last follow-up. After ACDF without plating, three radiological parameters were also initially improved compared with preoperative condition, but significantly deteriorated to preoperative levels at the time of the last follow-up. The fusion rate was higher in the ACDF with plating group compared with the ACDF without plating group (90.9% vs. 63.6%; P < 0.01). One patient who received ACDF with plating and four patients who received ACDF without plating underwent revision surgery due to nonunion or bone graft dislodgement. No recurrence of pyogenic spondylodiscitis occurred in either group.

CONCLUSION

ACDF with plating showed better surgical outcomes compared with ACDF without plating for CPS. We recommend the use of anterior cervical plating, which can provide biomechanical stability, for better healing of CPS. To our knowledge, this is the largest surgical case series of CPS.

LEVEL OF EVIDENCE

4.

Debridement and Interbody Graft Using Titanium Mesh Cage, Posterior Monosegmental Instrumentation, and Fusion in the Surgical Treatment of Monosegmental Lumbar or Lumbosacral Pyogenic Vertebral Osteomyelitis via a Posterior-Only Approach

OBJECTIVE

The main objective of the present study was to analyze the efficacy and feasibility of surgical management for patients with monosegmental lumbar or lumbosacral pyogenic vertebral osteomyelitis (PVO) by using one stage posterior debridement, interbody graft using titanium mesh cage, posterior monosegmental instrumentation, and fusion.

METHODS

From February 2014 to May 2016, 27 patients with lumbar or lumbosacral PVO were treated by posterior debridement, interbody graft using titanium mesh cage, posterior monosegmental instrumentation, and fusion. The degree of damage to the patients' vertebral bodies was one third to one half height. There were 16 male and 11 female, with a mean age of 43.5 years (range, 32-56 years) at the time of surgery. The mean follow-up time was 35.7 months (range, 26-53 months). The clinical efficacy was evaluated on average operation time, blood loss, visual analog scale, erythrocyte sedimentation rate, C-reactive protein level, and neurologic function recovery.

RESULTS

PVO was completely cured and the grafted bone was fused in all 27 patients. There was no recurrent vertebral osteomyelitis infection. Erythrocyte sedimentation rate and C-reactive protein level achieved normal limits within 3 months in all patients. The American Spinal Injury Association neurologic classification was improved in all cases. Pain relief was obtained in all patients.

CONCLUSIONS

Our results showed that one stage posterior debridement, interbody graft using titanium mesh cage, posterior monosegmental instrumentation, and fusion was an effective treatment for patients with one third to one half height of vertebral body damaged in monosegmental lumbar or lumbosacral PVO. The surgical method is characterized as minimum surgical trauma, good pain relief, good neurologic recovery, and good reconstruction of spinal stability.

One-stage Debridement via Oblique Lateral Interbody Fusion Corridor Combined with Posterior Pedicle Screw Fixation in Treating Spontaneous Lumbar Infectious Spondylodiscitis: A Case Series

Objective

Surgery is indicated when antibiotic treatment fails in pyogenic spondylodiscitis, which is caused by pathogens such as the Staphylococcus species. The aim of the present study was to investigate the efficacy and safety of the oblique lateral interbody fusion (OLIF) corridor approach combined with posterior pedicle screw fixation for treating pyogenic spondylodiscitis.

Methods

This was a retrospective case series study. A total of 11 patients with an average age of 60.7 years (range, 40–70 years; 10 males and 1 females) with lumbar pyogenic spondylodiscitis who underwent single‐stage debridement and reconstruction using the OLIF corridor combined with posterior pedicle screw fixation were recruited in our study from June 2016 to July 2017. All patients had single‐level pyogenic spondylodiscitis between T₁₂ and L₅. The baseline data, perioperative outcomes (operative time, intra‐operative blood loss, and intra‐operative complication), postoperative laboratory tests (erythrocyte sedimentation rate [ESR], C‐reactive protein [CRP], white blood count [WBC], and tissue culture results), long‐term complications (recurrence, fixation failure, and bony non‐fusion rates), and duration of antibiotic administration were reviewed. Outcomes evaluated using a variety of scales including visual analog scale (VAS) score and Oswestry disability index (ODI), were compared pre‐operatively and post‐operatively.

Results

The mean follow‐up period of time was 18.3 months. The average operative time and intra‐operative blood loss were 217.0 ± 91.91 min and 220.9 ± 166.10 mL, respectively. There were no intra‐operative complications, except in 1 patient who encountered somatosensory evoked potentials changes and 1 patient who had motor evoked potentials changes, both without post‐surgery neurological deficits. Causative organisms were identified in 4 patients: Staphylococcus aureus in 1 patient and Streptococcus in 3 patients. At approximately 8.8 weeks after surgery, WBC, CRP, and ESR had returned to normal levels. All patients were pain free with no recurring infection. There was no fixation failure during follow up. Solid bony fusions were observed in all cases within 6 months. At the final follow up, the mean VAS (0.6 ± 0.69) and ODI (14.4 ± 4.27) were significantly lower than those before surgery (P < 0.05).

Conclusion

One‐stage debridement with autogenous iliac bone graft through the OLIF corridor combined with posterior pedicle screw fixation is effective and safe for single‐level spontaneous lumbar pyogenic spondylodiscitis after antibiotic treatment fails.

Surgical Treatment With Thoracic Pedicle Screw Fixation of Vertebral Osteomyelitis With Long-Term Follow-up

BACKGROUND

While recent data has demonstrated the utility of lumbar pedicle screws for the treatment of vertebral osteomyelitis, the data are limited for thoracic pedicle screws.

OBJECTIVE

To investigate the effectiveness of thoracic pedicle screws for the surgical treatment of vertebral osteomyelitis.

METHODS

A retrospective review of all operations performed by 2 spinal neurosurgeons from 1999 to 2012 yielded 30 cases of vertebral osteomyelitis that were treated with thoracic pedicle screws. Sixteen (53%) of which underwent combined anterior and posterior fusion and 14 patients (47%) underwent standalone posterior fusion. Postoperative records were analyzed for pertinent clinical, laboratory, and radiographic data.

RESULTS

Of the 30 patients, 21 were males (70%), 8 were females (27%), and 1 was transsexual (3%). The mean age was 47 yr (range 18-69). The most common organism cultured was Staphylococcus aureus in 12 cases (50%). The mean patient stay in the hospital was 12.4 d after surgery (range 5-38 d). The mean antibiotic duration after discharge was 8 wk (range 1-24 wk). Of the 25 patients with long-term follow-up (mean, 49 mo), 92% had improved back pain (6/25 marked improvement, 17/25 complete resolution), 83% had improved muscle weakness (8/18 marked improvement, 7/18 complete resolution), and 100% had improved urinary incontinence (3/8 marked improvement, 5/8 complete resolution). Two patients (7%) required additional surgical revision due to instrumentation failure or wound infection.

CONCLUSION

This study demonstrates the efficacy of utilizing thoracic pedicle screws as a primary intervention to treat vertebral osteomyelitis.

Continuous Epidural Irrigation and Drainage Combined with Posterior Debridement and Posterior Lumbar Inter-Body Fusion for the Management of Single-Segment Lumbar Pyogenic Spondylodiscitis

Purpose: To observe the clinical curative effect of continuous epidural irrigation combined with posterior debridement and posterior lumbar inter-body fusion with instrumentation for the therapy of single-segment lumbar pyogenic spongdylodiscitis. Methods: From June 2010 to November 2013, surgical treatment was performed in 18 patients with pyogenic spondylodiscitis. The surgical indications were progressive biomechanical instability, epidural abscesses, deterioration of neurologic status, and intractable back pain. All these patients received posterior decompression with posterior instrumentation, debridement of infected tissue, and inter-body fusion. Visual Analogue Scale (VAS) scores were used to assess clinical outcomes. The neural function was evaluated by the Frankel grading system. Laboratory and radiologic results were recorded during clinical follow-up for at least one year. Results: The average follow-up period was 18 months after the operation. The VAS scores decreased from an average of 7.1 points before the procedure to 2.6 points after operation. The neurologic deficits of all the patients were recovered to Frankel grade E. All of the examined laboratory parameters were normalized gradually. Imaging-documented fusion was achieved in each patient, and no implants failure was noted. No patients showed any evidence of recurrence or persistence of infection. Conclusion: In carefully selected patients, single-segment lumbar pyogenic spondylodiscitis can be cured successfully with continuous epidural irrigation and drainage combined with posterior debridement and posterior lumbar inter-body fusion. Instrumentation could provide immediate stability and reconstruction of the spine column, and the presence of instrumentation did not result in any persistence or recurrence of infection. Continuous epidural irrigation and drainage is an effective method facilitating the elimination of residual infection.

Adaptation and limitation of anterior column reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine

BACKGROUND

Surgical strategy for pyogenic spondylitis is controversial when vertebral body erosion is severe. Radical debridement and anterior column reconstruction is indicated for the purpose of early ambulatory to prevent secondary complication for long bed rest. However, such aggressive debridement and risk of perioperative complications are trade-off. The purpose of this study was to evaluate the risk factor of poor prognosis after anterior column debridement and reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine.

METHODS

We performed a retrospective review of 40 patients diagnosed with pyogenic spondylitis in lower thoracic and lumbar spine who were introduced to our institution due to losing ambulatory ability and underwent anterior column debridement and reconstruction between January 2008 and May 2016. After the patient population was split into a regaining ambulatory group (Group A; n = 23) and a poor prognosis group (Group P; n = 17), we used Fisher exact tests and t-tests as appropriate for univariate analyses to compare patient characteristics and outcomes between the 2 groups.

RESULTS

Univariate analysis showed that the significant variables were massive bleeding (>2000 ml) (P < 0.01), Charlson Comorbidity Index ≥3 (P = 0.01), and two-stage surgery needed (P = 0.04). Logistic regression analysis showed that the factors associated with poor prognosis were massive bleeding (Odds Ratio 11.9; 95% confidence interval 1.8 to 119.7; P = 0.04).

CONCLUSIONS

Massive bleeding was associated with poor prognosis after debridement followed by anterior column reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine.

Pyogenic Vertebral Osteomyelitis: Clinical Features, Diagnosis, and Treatment

Pyogenic vertebral osteomyelitis (PVO) may result in neurological deficits and sequelae, so early diagnosis and appropriate treatment are critical. Many previous studies on PVO exist, but our paper has aimed to comprehensively summarize the clinical aspects of PVO. Through review of the vast literature on the clinical research of PVO an overview of the clinical characteristics, diagnostic methods, treatment and prognosis is provided.

Posterior-Only Circumferential Decompression and Reconstruction in the Surgical Management of Lumbar Vertebral Osteomyelitis

Study Design Case report. Objective The purpose of this report is to discuss the surgical management of lumbar vertebral osteomyelitis with a spinal epidural abscess (SEA) and present a single-stage, posterior-only circumferential decompression and reconstruction with instrumentation using an expandable titanium cage and without segmental nerve root sacrifice as an option in the treatment of this disease process. Methods We report a 42-year-old man who presented with 3 days of low back pain and chills who rapidly decompensated with severe sepsis following admission. Magnetic resonance imaging of his lumbosacral spine revealed intramuscular abscesses of the left paraspinal musculature and iliopsoas with SEA and L4 vertebral body involvement. The patient failed maximal medical treatment, which necessitated surgical treatment as a last resort for infectious source control. He underwent a previously undescribed procedure in the setting of SEA: a single-stage, posterior-only approach for circumferential decompression and reconstruction of the L4 vertebral body with posterior segmental instrumented fixation. Results After the surgery, the patient's condition gradually improved; however, he suffered a wound dehiscence necessitating a surgical exploration and deep wound debridement. Six months after the surgery, the patient underwent a revision surgery for adjacent-level pseudarthrosis. At 1-year follow-up, the patient was pain-free and off narcotic pain medication and had returned to full activity. Conclusion This patient is the first reported case of lumbar osteomyelitis with SEA treated surgically with a single-stage, posterior-only circumferential decompression and reconstruction with posterior instrumentation. Although this approach is more technically challenging, it presents another viable option for the treatment of lumbar vertebral osteomyelitis that may reduce the morbidity associated with an anterior approach.

Safety of instrumentation and fusion at the time of surgical debridement for spinal infection

The present study aims to assess the results of single-stage instrumentation and fusion at the time of surgical debridement of spinal infections; vertebral osteomyelitis or epidural abscess. Nine patients with spinal infection were treated with instrumentation and fusion after radical debridement in a single-stage operation. Predisposing factors and comorbidities, pain, American Spinal Injury Association motor scores, primary pathologies, microbiology and perioperative markers were recorded. Seven patients with pyogenic and two with tuberculous spinal infection were encountered; the most common pathogen was Staphylococcus aureus. Five patients were predisposed to infection because of diabetes mellitus. Duration of antibiotic therapy lasted up to 12 months. Six patients had thoracic infection, two lumbar and one cervical. No post-operative complications were encountered. There was a significant reduction in pain scores compared to pre-operatively. All patients with neurological deficits improved post-operatively. Despite introduction of hardware, no patients had a recurrence of their infection in the 12 month follow up period. Single-stage debridement and instrumentation appeared to be a safe and effective method of managing spinal infections. The combination of debridement and fusion has the dual benefit of removing a focus of infection and stabilising the spine. The current series confirms that placing titanium cages into an infected space is safe in a majority of patients. Stabilisation and correction of spinal deformity reduces pain, aids neurologic recovery and improves quality of life. The small patient population and retrospective nature limit the present study.