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Gamada H, Funayama T, Setojima Y, Nagasawa K, Nakagawa T, Sakashita K, Okuwaki S, Ogawa K, Izawa S, Shibao Y, Kumagai H, Nagashima K, Fujii K, Takeuchi Y, Tatsumura M, Shiina I, Uesugi M, Yamazaki M, Koda M. 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. BMC Musculoskelet Disord 2024; 25:458. [PMID: 38858717 PMCID: PMC11163737 DOI: 10.1186/s12891-024-07565-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/03/2024] [Indexed: 06/12/2024] Open
Abstract
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.
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Affiliation(s)
- Hisanori Gamada
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Orthopaedic Surgery, Ibaraki Western Medical Center, Chikusei, Ibaraki, Japan
| | - Toru Funayama
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
- Department of Orthopaedic Surgery, Kenpoku Medical Center, Takahagi Kyodo Hospital, Takahagi, Ibaraki, Japan.
| | - Yusuke Setojima
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Orthopaedic Surgery, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Keigo Nagasawa
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Orthopaedic Surgery, Showa General Hospital, Kodaira, Tokyo, Japan
- Department of Orthopaedic Surgery, Moriya Daiichi General Hospital, Moriya, Ibaraki, Japan
| | - Takane Nakagawa
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Orthopaedic Surgery, Ichihara Hospital, Tsukuba, Ibaraki, Japan
| | - Kotaro Sakashita
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shun Okuwaki
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Orthopaedic Surgery, Kenpoku Medical Center, Takahagi Kyodo Hospital, Takahagi, Ibaraki, Japan
| | - Kaishi Ogawa
- Department of Orthopaedic Surgery, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Shigeo Izawa
- Department of Orthopaedic Surgery, Tsukuba Central Hospital, Ushiku, Ibaraki, Japan
| | - Yosuke Shibao
- Department of Orthopaedic Surgery, Ibaraki Western Medical Center, Chikusei, Ibaraki, Japan
| | - Hiroshi Kumagai
- Department of Orthopaedic Surgery, Ichihara Hospital, Tsukuba, Ibaraki, Japan
| | - Katsuya Nagashima
- Department of Orthopaedic Surgery and Sports Medicine, Tsukuba University Hospital, Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Mito, Ibaraki, Japan
| | - Kengo Fujii
- Department of Orthopaedic Surgery, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Yosuke Takeuchi
- Department of Orthopaedic Surgery and Sports Medicine, Tsukuba University Hospital, Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Mito, Ibaraki, Japan
| | - Masaki Tatsumura
- Department of Orthopaedic Surgery and Sports Medicine, Tsukuba University Hospital, Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Mito, Ibaraki, Japan
| | - Itsuo Shiina
- Department of Orthopaedic Surgery, Moriya Daiichi General Hospital, Moriya, Ibaraki, Japan
| | - Masafumi Uesugi
- Department of Orthopaedic Surgery, Ibaraki Seinan Medical Center Hospital, Sakai, Ibaraki, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Masao Koda
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Maki Y, Fukaya K. Two-Stage Cervical and Thoracic-Lumbar-Sacral Circumferential Fixation for Pyogenic Spondylitis: A Case Report. Cureus 2024; 16:e53070. [PMID: 38410351 PMCID: PMC10896660 DOI: 10.7759/cureus.53070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2024] [Indexed: 02/28/2024] Open
Abstract
Pyogenic spondylitis is a rare life-threatening condition. Conservative treatment with antibiotics is indicated; however, surgery can be considered in refractory cases. The surgical strategy varies, as pyogenic spondylosis can occur from the cervical to sacral regions. To our knowledge, although there is less invasiveness as an advantage in the following management, cervical and thoracic-lumbar-sacral circumferential fixations in two sessions for pyogenic spondylitis have not been previously described. An 84-year-old man complained of ambulation disturbances and pain in the neck and upper and lower extremities (the Japan Orthopaedic Association cervical myelopathy evaluation questionnaire score of 5/17). Magnetic resonance imaging revealed pyogenic spondylitis of the cervical, thoracic, and lumbar regions. Epidural abscesses and spondylodiscitis were concurrently diagnosed with multi-level skipping lesions from the cervical to the sacral regions. As these lesions were resistant to antibiotic treatment and the neurological symptoms worsened, surgical treatment was planned. Anterior cervical discectomy and fusion, and posterior cervical fixation were followed by oblique and posterior lumbar intervertebral fusions with long-level fixation from T12 to the ilium using percutaneous pedicle screws. The surgeries were performed in two sessions to avoid the invasiveness of surgeries in a single session. The patient's condition improved after a second surgery. The patient was discharged on postoperative day 116. No recurrence was observed for six months, and the patient was able to ambulate independently. Two-stage cervical and thoracic-lumbar-sacral circumferential fixation for pyogenic spondylitis contributed to a favorable outcome (the Japan Orthopaedic Association cervical myelopathy evaluation questionnaire score of 13/17).
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Affiliation(s)
- Yoshinori Maki
- Neurosurgery, Hikone Chuo Hospital, Hikone, JPN
- Rehabilitation, Hikari Hospital, Otsu, JPN
| | - Kenji Fukaya
- Neurosurgery, Ayabe Renaiss Hospital, Ayabe, JPN
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Gonzalez GA, Porto G, Tecce E, Oghli YS, Miao J, O'Leary M, Chadid DP, Vo M, Harrop J. Advances in diagnosis and management of atypical spinal infections: A comprehensive review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100282. [PMID: 37915965 PMCID: PMC10616400 DOI: 10.1016/j.xnsj.2023.100282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/28/2023] [Accepted: 09/24/2023] [Indexed: 11/03/2023]
Abstract
Atypical spinal infections (ASIs) of the spine are a challenging pathology to management with potentially devastating morbidity and mortality. To identify patients with atypical spinal infections, it is important to recognize the often insidious clinical and radiographic presentations, in the setting of indolent and smoldering organism growth. Trending of inflammatory markers, and culturing of organisms, is essential. Once identified, the spinal infection should be treated with antibiotics and possibly various surgical interventions including decompression and possible fusion depending on spine structural integrity and stability. Early diagnosis of ASIs and immediate treatment of debilitating conditions, such as epidural abscess, correlate with fewer neurological deficits and a shorter duration of medical treatment. There have been great advances in surgical interventions and spinal fusion techniques for patients with spinal infection. Overall, ASIs remain a perplexing pathology that could be successfully treated with early diagnosis and immediate, appropriate medical, and surgical management.
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Affiliation(s)
- Glenn A. Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Guilherme Porto
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Eric Tecce
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Yazan Shamli Oghli
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Jingya Miao
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - Matthew O'Leary
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | | | - Michael Vo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 909 Walnut St, Philadelphia, PA 19107, United States
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Yunoki M. A Comprehensive Review of Pyogenic Spondylitis Management for Neurosurgeons. Asian J Neurosurg 2023; 18:724-733. [PMID: 38161608 PMCID: PMC10756848 DOI: 10.1055/s-0043-1777272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Older populations have been increasing recently, resulting in an increase in cases of pyogenic spondylitis. Neurosurgeons who frequently treat the elderly are at a higher risk of encountering this condition. Therefore, this article provides a summary of the literature and our experience to help neurosurgeons effectively manage pyogenic osteomyelitis. It is important not to rule out pyogenic spondylosis when examining a patient with back pain, even in the absence of a fever. This is because the chronic type is common, easily overlooked, and early diagnosis and treatment are crucial. Empirical antibiotics should be avoided in cases where blood culture and biopsy are negative, to prevent microbial resistance and an increase in difficult-to-treat cases. Biopsies, such as computed tomography-guided percutaneous biopsy and full endoscopic debridement and drainage, should be attempted. Currently, 6 weeks of parenteral antibiotic therapy is the main treatment for pyogenic spondylitis. Surgical treatment is recommended if this method is ineffective. However, in the early stages, full endoscopic debridement and drainage and percutaneous pedicle screw fixation are optional.
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Affiliation(s)
- Masatoshi Yunoki
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagaw, Japan
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Lacasse M, Derolez S, Bonnet E, Amelot A, Bouyer B, Carlier R, Coiffier G, Cottier JP, Dinh A, Maldonado I, Paycha F, Ziza JM, Bemer P, Bernard L. 2022 SPILF - Clinical Practice guidelines for the diagnosis and treatment of disco-vertebral infection in adults. Infect Dis Now 2023; 53:104647. [PMID: 36690329 DOI: 10.1016/j.idnow.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/12/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023]
Abstract
These guidelines are an update of those made in 2007 at the request of the French Society of Infectious Diseases (SPILF, Société de Pathologie Infectieuse de Langue Française). They are intended for use by all healthcare professionals caring for patients with disco-vertebral infection (DVI) on spine, whether native or instrumented. They include evidence and opinion-based recommendations for the diagnosis and management of patients with DVI. ESR, PCT and scintigraphy, antibiotic therapy without microorganism identification (except for emergency situations), therapy longer than 6 weeks if the DVI is not complicated, contraindication for spinal osteosynthesis in a septic context, and prolonged dorsal decubitus are no longer to be done in DVI management. MRI study must include exploration of the entire spine with at least 2 orthogonal planes for the affected level(s). Several disco-vertebral samples must be performed if blood cultures are negative. Short, adapted treatment and directly oral antibiotherapy or early switch from intravenous to oral antibiotherapy are recommended. Consultation of a spine specialist should be requested to evaluate spinal stability. Early lifting of patients is recommended.
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Affiliation(s)
- M Lacasse
- Medecine Interne et Maladies Infectieuses, 2 Bd Tonnelé, CHU Bretonneau, 37044 Tours Cedex 09, France
| | - S Derolez
- Rhumatologie, 125 rue de Stalingrad, CHU Avicenne, 93000 Bobigny, France
| | - E Bonnet
- Maladies Infectieuses, Pl. Dr Baylac, CHU Purpan, 31000 Toulouse, France.
| | - A Amelot
- Neurochirurgie, 2 Bd Tonnelé, CHU Bretonneau, 37044 Tours Cedex 09, France
| | - B Bouyer
- Chirurgie orthopédique et traumatologique, CHU de Bordeaux, Place Amélie Raba-léon, 33076 Bordeaux, France
| | - R Carlier
- Imagerie, Hôpital Raymond Poincaré, 104 Bd R Poincaré, 92380 Garches, France
| | - G Coiffier
- Rhumatologie, GH Rance-Emeraude, Hôpital de Dinan, 22100 Dinan, France
| | - J P Cottier
- Radiologie, 2 Bd Tonnelé, CHU Bretonneau, 37044 Tours Cedex 09, France
| | - A Dinh
- Maladies Infecteiuses, CHU Raymond Poicaré, 92380 Garches, France
| | - I Maldonado
- Radiologie, 2 Bd Tonnelé, CHU Bretonneau, 37044 Tours Cedex 09, France
| | - F Paycha
- Médecine Nucléaire, Hôpital Lariboisière, 2 rue Ambroise Paré 75010 Paris, France
| | - J M Ziza
- Rhumatologie et Médecine Interne. GH Diaconesses Croix Saint Simon, 75020 Paris, France
| | - P Bemer
- Microbiologie, CHU de Nantes, 1 Place A. Ricordeau, Nantes 44000 Cedex 1, France
| | - L Bernard
- Medecine Interne et Maladies Infectieuses, 2 Bd Tonnelé, CHU Bretonneau, 37044 Tours Cedex 09, France
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Gamada H, Funayama T, Yamaji A, Okuwaki S, Asada T, Izawa S, Kumagai H, Fujii K, Amano K, Shiina I, Tatsumura M, Uesugi M, Nakagawa T, Yamazaki M, Koda M. Treatment of Thoracolumbar Pyogenic Spondylitis with Minimally Invasive Posterior Fixation without Anterior Lesion Debridement or Bone Grafting: A Multicenter Case Study. J Clin Med 2023; 12:jcm12030932. [PMID: 36769580 PMCID: PMC9918103 DOI: 10.3390/jcm12030932] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Hisanori Gamada
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Japan
- Department of Orthopaedic Surgery, Ibaraki Western Medical Center, 555 Otsuka, Chikusei 308-0813, Japan
- Correspondence: ; Tel.: +81-29-853-3219
| | - Toru Funayama
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Japan
| | - Akihiro Yamaji
- Department of Orthopaedic Surgery, Ichihara Hospital, 3691 Osone, Tsukuba 300-3253, Japan
| | - Shun Okuwaki
- Department of Orthopaedic Surgery, Kenpoku Medical Center, Takahagi Kyodo Hospital, 1006-9 Kamiteduna-Agehocho, Takahagi 318-0004, Japan
| | - Tomoyuki Asada
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Japan
| | - Shigeo Izawa
- Department of Orthopaedic Surgery, Tsukuba Central Hospital, 1589-3 Kashiwada-Cho, Ushiku 300-1211, Japan
| | - Hiroshi Kumagai
- Department of Orthopaedic Surgery, Ichihara Hospital, 3691 Osone, Tsukuba 300-3253, Japan
| | - Kengo Fujii
- Department of Orthopaedic Surgery, Showa General Hospital, 8-1-1 Hanakonagei, Kodaira 187-0002, Japan
| | - Kuniaki Amano
- Department of Orthopaedic Surgery, Tsukuba Central Hospital, 1589-3 Kashiwada-Cho, Ushiku 300-1211, Japan
| | - Itsuo Shiina
- Department of Orthopaedic Surgery, Moriya Daiichi Hospital, 1-17 Matsumaedai, Moriya 302-0102, Japan
| | - Masaki Tatsumura
- Department of Orthopaedic Surgery and Sports Medicine, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, 3-2-7 Miyamachi, Mito 310-0015, Japan
| | - Masafumi Uesugi
- Department of Orthopaedic Surgery, Ibaraki Seinan Medical Center Hospital, 2190 Sashima, Sakai 306-0433, Japan
| | - Tsukasa Nakagawa
- Department of Orthopaedic Surgery, Ibaraki Western Medical Center, 555 Otsuka, Chikusei 308-0813, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Japan
| | - Masao Koda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Japan
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Behmanesh B, Gessler F, Duetzmann S, Seifert V, Weise L, Setzer M. Quality of Life Following Surgical and Conservative Therapy of Pyogenic Spinal Infection: A Study of Long-term Outcome in 210 Patients. J Neurol Surg A Cent Eur Neurosurg 2023; 84:14-20. [PMID: 33690878 DOI: 10.1055/s-0041-1722965] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECT The management and recommendations for treatment strategies of pyogenic spinal infection are still a highly controversial issue. The purpose of this study was to evaluate patient's quality of life (QoL) after surgical and conservative treatment of spinal infection. MATERIALS AND METHODS We conducted a retrospective, single-center study. All patients treated between 2009 and 2016 were included in this study. For evaluation of QoL, we recorded each patient's satisfaction according to the 36-Item Short Form Health Survey (SF-36) questionnaire. Scores were compared with a U.S. standard population. RESULTS Two hundred and ten adult patients with spondylodiskitis were identified. Of these, 155 (74%) underwent surgery and 55 (26%) were treated conservatively. The mean overall age was 68.6 (23-98) years. Seventy-two patients were females and 138 patients were males. The mean outcome values in the surgical group did not reach the level of the normative sample in one of eight items, whereas the conservative group revealed a reduced QoL in all items. Intergroup comparison revealed significant differences in all items (p < 0.05). CONCLUSION In the patient population we investigated, QoL in surgically treated patients was better than that in conservatively managed patients.
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Affiliation(s)
- Bedjan Behmanesh
- Department of Neurosurgery, Goethe University Frankfurt, Schleusenweg, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, Goethe University Frankfurt, Schleusenweg, Frankfurt, Germany
| | - Stephan Duetzmann
- Department of Neurosurgery, Goethe-Universitat Frankfurt am Main Fachbereich 16 Medizin, Schleusenweg, Frankfurt, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-Universitat Frankfurt am Main Fachbereich 16 Medizin, Schleusenweg, Frankfurt, Germany
| | - Lutz Weise
- Department of Neurosurgery, Goethe-Universitat Frankfurt am Main Fachbereich 16 Medizin, Schleusenweg, Frankfurt, Germany
| | - Matthias Setzer
- Department of Neurosurgery, Goethe-Universitat Frankfurt am Main Fachbereich 16 Medizin, Schleusenweg, Frankfurt, Germany
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Scheyerer MJ, Herren C, Kühne C, Neufang J, Pieroh P, von der Höh NH. Surgical Treatment Strategies for Pyogenic Spondylodiscitis of the Thoracolumbar Spine. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2022; 160:621-628. [PMID: 34461670 DOI: 10.1055/a-1527-7939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Max J Scheyerer
- Department of Orthopaedics and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Christian Herren
- Clinic for Trauma and Reconstructive Surgery, University Hospital Aachen, Germany
| | - Christian Kühne
- Trauma and Hand Surgery, Schön Clinic Hamburg-Eilbek, Germany
| | - Jörg Neufang
- Spinal Surgery, Professional Accidents Clinic Murnau, Germany
| | - Philipp Pieroh
- Clinic and Polyclinic for Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig Medical Faculty, Germany
| | - Nicolas H von der Höh
- Clinic and Polyclinic for Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig Medical Faculty, Germany
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Ishii K, Watanabe G, Tomita T, Nikaido T, Hikata T, Shinohara A, Nakano M, Saito T, Nakanishi K, Morimoto T, Isogai N, Funao H, Tanaka M, Kotani Y, Arizono T, Hoshino M, Sato K. Minimally Invasive Spinal Treatment (MIST)—A New Concept in the Treatment of Spinal Diseases: A Narrative Review. Medicina (B Aires) 2022; 58:medicina58081123. [PMID: 36013590 PMCID: PMC9413482 DOI: 10.3390/medicina58081123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/05/2022] [Accepted: 08/16/2022] [Indexed: 11/23/2022] Open
Abstract
In the past two decades, minimally invasive spine surgery (MISS) techniques have been developed for spinal surgery. Historically, minimizing invasiveness in decompression surgery was initially reported as a MISS technique. In recent years, MISS techniques have also been applied for spinal stabilization techniques, which were defined as minimally invasive spine stabilization (MISt), including percutaneous pedicle screws (PPS) fixation, lateral lumbar interbody fusion, balloon kyphoplasty, percutaneous vertebroplasty, cortical bone trajectory, and cervical total disc replacement. These MISS techniques typically provide many advantages such as preservation of paraspinal musculature, less blood loss, a shorter operative time, less postoperative pain, and a lower infection rate as well as being more cost-effective compared to traditional open techniques. However, even MISS techniques are associated with several limitations including technical difficulty, training opportunities, surgical cost, equipment cost, and radiation exposure. These downsides of surgical treatments make conservative treatments more feasible option. In the future, medicine must become “minimally invasive” in the broadest sense—for all patients, conventional surgeries, medical personnel, hospital management, nursing care, and the medical economy. As a new framework for the treatment of spinal diseases, the concept of minimally invasive spinal treatment (MIST) has been proposed.
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Affiliation(s)
- Ken Ishii
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Chiba 286-8686, Japan
- Spine and Spinal Cord Center, Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo 108-8329, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Chiba 286-8520, Japan
| | | | - Takashi Tomita
- Department of Orthopaedic Surgery, Aomori Prefectural Central Hospital, Aomori 030-8553, Japan
| | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima 960-1295, Japan
| | - Tomohiro Hikata
- Department of Orthopaedic Surgery, Kitasato University Kitasato Institute Hospital, Tokyo 108-8642, Japan
| | - Akira Shinohara
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo 105-8471, Japan
| | - Masato Nakano
- Department of Orthopaedic Surgery, Takaoka City Hospital, Takaoka 933-8550, Japan
| | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, Osaka 573-1191, Japan
| | - Kazuo Nakanishi
- Department of Orthopaedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama 701-0192, Japan
| | - Tadatsugu Morimoto
- Department of Orthopaedic Surgery, Saga University School of Medicine, Saga 849-8501, Japan
| | - Norihiro Isogai
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Chiba 286-8686, Japan
- Spine and Spinal Cord Center, Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo 108-8329, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare (IUHW), Chiba 286-8686, Japan
- Spine and Spinal Cord Center, Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Mita Hospital, Tokyo 108-8329, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Chiba 286-8520, Japan
| | - Masato Tanaka
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan
| | - Yoshihisa Kotani
- Department of Orthopaedic Surgery, Kansai Medical University Medical Center, Osaka 573-1010, Japan
| | - Takeshi Arizono
- Department of Orthopaedic Surgery, Kyushu Central Hospital, Fukuoka 815-0032, Japan
| | - Masahiro Hoshino
- Department of Orthopaedic Surgery, Sonoda Medical Institute Tokyo Spine Center, Tokyo 121-0807, Japan
| | - Koji Sato
- Department of Orthopaedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya 466-8650, Japan
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10
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The History and Development of the Percutaneous Pedicle Screw (PPS) System. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081064. [PMID: 36013531 PMCID: PMC9414999 DOI: 10.3390/medicina58081064] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/19/2022]
Abstract
Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) using the SEXTANT® system (Medtronic) featured the first generation of commercially available percutaneous pedicle screw (PPS) system in 2001. The innovative system has since become standard instrumentation used worldwide, and PPS is now used for long-segment minimally invasive surgery (MIS) spinal fixation from the thoracic spine to the pelvis for pathological conditions. PPS systems have been developed for approximately 20 years for the purpose of improving minimally invasive techniques, safety of instrumentation, and ease of use. The third-generation PPS systems established the insertion technique, and the development of the fourth-generation PPS systems have made great strides in minimizing the number of steps in the operative procedure. In the future, PPS systems are expected to continue making use of the latest technological advancements and to develop further with the aim of ensuring greater safety, reducing operator stress, and preventing complications such as insertion errors and infection. In this review article, we describe the historical evolution from the first-generation PPS system to the current PPS systems used today.
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Chen ZH, Wang X, Zhang Y, Wu ST, Wu YH, Shi Q, Zhang BK, Xu JG, Chen XH, Lian XF. Percutaneous Transforaminal Endoscopic Debridement and Drainage with Accurate Pathogen Detection for Infectious Spondylitis of the Thoracolumbar and Lumbar Spine. World Neurosurg 2022; 164:e1179-e1189. [PMID: 35660670 DOI: 10.1016/j.wneu.2022.05.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE In this study, we aimed to analyze the clinical outcomes of percutaneous transforaminal endoscopic debridement and drainage (PTEDD) with accurate pathogen detection for patients with infectious spondylitis of the thoracolumbar and lumbar spines. METHODS From January 2017 to February 2019, a consecutive series of 43 patients with infectious spondylitis of the thoracolumbar and lumbar spine were surgically treated with PTEDD. Organism culture, next-generation DNA sequencing, and pathological examination of the sample extracted from the infectious site were performed for accurate microbiological diagnosis. All patients were followed up for 24-36 months. Clinical and radiological outcomes were analyzed preoperatively and postoperatively. RESULTS Surgeries were completed successfully on all 43 patients under local infiltration anesthesia. Positive culture of the responsible organism was obtained in 33 cases (76.7%). Among the 43 patients who underwent next-generation DNA sequencing, 42 (97.7%) had positive results. Corresponding antibiotic medication was given based on the pathogen detection. The modified Macnab criteria were found to be excellent in 32 patients (74.4%) and good in 11 (25.6%). Postoperative magnetic resonance imaging showed that the abscess and infectious area were reduced significantly at 3 months and had disappeared or almost disappeared at the final follow-up. Spontaneous fusion was obtained in 30 patients (69.8%). No patients required revision or conversion to open debridement and reconstruction. CONCLUSIONS For patients with infectious spondylitis of the thoracolumbar and lumbar spine, PTEDD is an effective and safe treatment. Next-generation DNA sequencing is a much more sensitive method for detecting the responsible organisms.
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Affiliation(s)
- Zhi-Heng Chen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xin Wang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Zhang
- Department of Infectious Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Sheng-Ting Wu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ying-Hao Wu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qiang Shi
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Bao-Kun Zhang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jian-Guang Xu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiao-Hua Chen
- Department of Infectious Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiao-Feng Lian
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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12
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Yamada K, Ieguchi M, Takahashi S, Nakamura H. Life Expectancy Is Poor in Patients with Diffuse Idiopathic Skeletal Hyperostosis-Related Pyogenic Vertebral Osteomyelitis. Spine Surg Relat Res 2022; 6:654-663. [PMID: 36561153 PMCID: PMC9747224 DOI: 10.22603/ssrr.2022-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/03/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Pyogenic vertebral osteomyelitis (PVO) is an uncommon but life-threatening infectious disease. Diffuse idiopathic skeletal hyperostosis (DISH) is an age-related disorder and sometimes problematic in terms of spinal instability or high mortality, especially in cases of DISH-related fracture. Meanwhile, no reports have focused on the impact of DISH on the clinical outcomes after treatment for PVO. We hypothesized that PVO occurring at DISH-related segments might contribute to poor clinical results or high mortality rates. The purpose of this study was to investigate the impact of DISH on mortality after treatment for PVO in a retrospective cohort study. Methods This study involved patients who were hospitalized and treated for PVO at a single institution. DISH-related PVO was defined as PVO within a segment ossified by DISH or PVO at the neighboring intervertebral level of the segment ossified by DISH. Differences in mortality between patients with DISH-related and non-DISH-related PVO were investigated. Results This study included 55 patients. DISH-related PVO was observed in 13 patients. The mortality rate was significantly higher in patients with DISH-related PVO than in those with non-DISH-related PVO (62% and 23%, respectively; p=0.016). Propensity score-adjusted analysis showed that DISH-related PVO was an independent risk factor for mortality (adjusted hazard ratio, 2.79; p=0.034). The survival probability was significantly shorter in patients with DISH-related PVO than in those with non-DISH-related PVO (p=0.006). PVO in which the intravertebral body was the center of involvement was significantly more common in DISH-related PVO than in non-DISH-related PVO (38% and 5%, respectively; p=0.006). Conclusions DISH-related PVO was associated with a higher mortality rate and shorter life expectancy than non-DISH-related PVO. Similar to advanced age, PVO at the segment ossified by DISH should be recognized as a risk factor for mortality when choosing the optimal treatment strategy.
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Affiliation(s)
- Kentaro Yamada
- Department of Orthopaedic Surgery, Fuchu Hospital, Izumi, Japan,Department of Orthopaedic Surgery, Osaka Metropolitan University, Osaka, Japan
| | - Makoto Ieguchi
- Department of Orthopaedic Surgery, Fuchu Hospital, Izumi, Japan
| | - Shinji Takahashi
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Osaka, Japan
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Tani Y, Saito T, Taniguchi S, Ishihara M, Paku M, Adachi T, Ando M, Kotani Y. 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. Medicina (B Aires) 2022; 58:medicina58040478. [PMID: 35454317 PMCID: PMC9025525 DOI: 10.3390/medicina58040478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/14/2022] [Accepted: 03/23/2022] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Yoichi Tani
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata 573-1010, Japan; (T.S.); (S.T.); (M.I.); (M.P.); (T.A.); (M.A.)
- Correspondence: ; Tel.: +81-72-804-2439
| | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata 573-1010, Japan; (T.S.); (S.T.); (M.I.); (M.P.); (T.A.); (M.A.)
| | - Shinichiro Taniguchi
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata 573-1010, Japan; (T.S.); (S.T.); (M.I.); (M.P.); (T.A.); (M.A.)
| | - Masayuki Ishihara
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata 573-1010, Japan; (T.S.); (S.T.); (M.I.); (M.P.); (T.A.); (M.A.)
| | - Masaaki Paku
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata 573-1010, Japan; (T.S.); (S.T.); (M.I.); (M.P.); (T.A.); (M.A.)
| | - Takashi Adachi
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata 573-1010, Japan; (T.S.); (S.T.); (M.I.); (M.P.); (T.A.); (M.A.)
| | - Muneharu Ando
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata 573-1010, Japan; (T.S.); (S.T.); (M.I.); (M.P.); (T.A.); (M.A.)
| | - Yoshihisa Kotani
- Department of Orthopaedic Surgery, Kansai Medical University Medical Center, 10-15 Fimizono-cho, Moriguchi 570-8507, Japan;
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Fujii K, Funayama T, Li S, Yamazaki M. Secondary Infection/Microbial Substitution in a Managed Case of Pyogenic Spondylitis. Cureus 2021; 13:e16432. [PMID: 34422467 PMCID: PMC8369970 DOI: 10.7759/cureus.16432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 11/23/2022] Open
Abstract
Pyogenic spondylitis is a challenging condition that requires early and accurate diagnosis for appropriate treatment. Most cases can be treated non-surgically or with minimally invasive surgical procedures; however, a combination of anterior debridement/bone grafting and posterior fixation is necessary for severe cases. We encountered a case of lumbar pyogenic spondylitis treated with anterior debridement and autogenous bone grafting after percutaneous endoscopic discectomy drainage (PEDD) with percutaneous pedicle screw (PPS) fixation. The continuous pus oozing from the PEDD drainage tube wound was characteristic in this case, and the pus was considered to be caused by secondary infection/microbial substitution. The discharge immediately stopped and healed after anterior debridement and autogenous bone grafting. Escherichia coli was first detected as the causative bacterium, and Corynebacterium amycolatum and Corynebacterium striatum were detected as the cause of secondary infection/microbial substitution. The possibility of secondary infection/microbial substitution should be considered when the clinical course worsens.
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Affiliation(s)
- Kengo Fujii
- Orthopedic Surgery, Showa General Hospital, Kodaira, JPN
| | - Toru Funayama
- Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Sayori Li
- Orthopedic Surgery, Showa General Hospital, Kodaira, JPN
| | - Masashi Yamazaki
- Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
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Mohamed AA, Soffar HM, El Zayat HH, Aboul-Ela HM. Prognosis of spinal infections managed by minimal debridement: A case series in two tertiary centers. Surg Neurol Int 2021; 12:83. [PMID: 33767887 PMCID: PMC7982097 DOI: 10.25259/sni_29_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/13/2021] [Indexed: 12/18/2022] Open
Abstract
Background Spinal infections can be challenging in their management and include spondylitis, epidural abscess, and spondylodiscitis. Usual treatment is conservative through antimicrobials or surgery to decompress neural tissue, debride all infected tissues, and fix if needed. We propose the concept of surgery without formal debridement aiming at neural protection. Methods The study was performed at two tertiary centers on 25 patients with clinical findings. One patient was treated conservatively and the rest surgically by laminectomy and fixation if needed. Evacuation of fluid pus was performed. In the cervical and the thoracic region, if the granulation tissue was anterior to the cord, only decompression by laminectomy was done. Results Low back pain was present in 22 cases (88%), 16 cases (64%) had lower limb pain, and 12 cases (48%) had weakness. The level of spinal infection was lumbar in 15 cases (60%), thoracic in 9 cases (36%) cases, and cervical in 1 case (4%). The type of infection was epidural abscess in 20 cases (80%), discitis in 16 cases (64%), and vertebral osteomyelitis in 12 cases (48%). Laminectomy was performed in 20 cases (80%) and fixation in 17 cases (68%). The symptoms improved in all cases. On follow-up, the lesion was reduced in 14 patients (56%) and disappeared in 11 cases (44%). One case required ventriculoperitoneal shunt placement due to postinfectious hydrocephalus. Conclusion Dealing with spinal infections surgically through decompression or fixation with minimal debridement of infected tissue appears to be a safe and effective method of management.
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Affiliation(s)
- Ahmed Ali Mohamed
- Department of Neurosurgery, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | | | - Hazem Hassan El Zayat
- Department of Neurosurgery, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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Choi SH, Koo JW, Hur JM, Kang CN. A New Surgical Strategy for Infective Spondylodiscitis: Comparison Between the Combined Antero-Posterior and Posterior-Only Approaches. Spine (Phila Pa 1976) 2020; 45:E1239-E1248. [PMID: 32453237 DOI: 10.1097/brs.0000000000003544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To investigate the radiographic and clinical effectiveness of surgical treatment using a posterior-only approach, as compared with a combined antero-posterior approach, in patients with infective spondylodiscitis. SUMMARY OF BACKGROUND DATA Spondylodiscitis is the most common infectious disease of the spine. There is currently no consensus over the surgical approach, use of bone graft, and type of instrumentation for optimal treatment of infective spondylodiscitis. METHODS Seventy-nine patients who received surgical treatment for infective spondylodiscitis were divided into a combined antero-posterior (AP) group and a posterior-only (P) group. Significant differences in pre- and postoperative radiographic and clinical characteristics between the two groups were identified, and univariate and stepwise multivariate logistic regression analyses were used to determine the factors that affected the decision for treatment approach between the two groups. RESULTS Preoperatively, initial height loss, wedge angle, and kyphotic angle were significantly higher in the AP group. However, estimated blood loss, operation time, and last visual analogue scale score for back pain were significantly lower in the P group. There was no difference in postoperative time to reach solid fusion. Postoperative corrected kyphotic angle was 12.8° in the AP group and 5.3° in the P group. The regional wedge angle was identified as a factor that influenced use of the combined antero-posterior approach, with a sensitivity of 60%, and specificity of 89.8% at the optimal cut-off value of 8.2°. CONCLUSION Interbody fusion with long-level pedicle screws fixation through a posterior-only approach was shown to be as effective as a combined antero-posterior approach for the surgical treatment of infective spondylodiscitis. A posterior-only approach is recommended when the regional wedge angle of the collapsed vertebra is less than 8.2°. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Sung Hoon Choi
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Republic of Korea
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Zhang CH, Zaidman N, Russo V. Hybrid Minimally Invasive Technique for Treatment of Thoracolumbar Spondylodiscitis and Vertebral Osteomyelitis. World Neurosurg 2020; 141:e752-e762. [PMID: 32526368 DOI: 10.1016/j.wneu.2020.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/31/2020] [Accepted: 06/02/2020] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Catherine Hao Zhang
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
| | - Nathalie Zaidman
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Vittorio Russo
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Duan K, Qin Y, Ye J, Zhang W, Hu X, Zhou J, Gao L, Tang Y. Percutaneous endoscopic debridement with percutaneous pedicle screw fixation for lumbar pyogenic spondylodiscitis: a preliminary study. INTERNATIONAL ORTHOPAEDICS 2020; 44:495-502. [PMID: 31879810 PMCID: PMC7026210 DOI: 10.1007/s00264-019-04456-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/21/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To access the feasibility and efficacy of percutaneous endoscopic debridement (PED) combined with percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar pyogenic spondylodiscitis. METHODS Forty-five patients diagnosed as pyogenic spondylodiscitis underwent PPSF followed by PED. A drainage catheter was left in place for negative pressure drainage. Adequate systematic antibiotics were administered empirically or based on bacterial culture results. Clinical outcomes were assessed by physical examination, regular serologic testing, visual analog scale (VAS), Oswestry Disability Index (ODI), and imaging studies. RESULTS The mean operative time was 110.1 ± 21.2 minutes (range 80-165 minutes), with intra-operative blood loss 47.8 ± 21.0 ml (range 20-120 ml). All patients reported relief of back pain, able to sit up, and partially ambulate the next day. Causative pathogens were identified in 32 of 45 biopsy specimens, staphylococcal bacteria being the most prevalent strain. However, there were 13 patients with post-operative complications. During 6-12 months' follow-up, inflammatory markers showed infection controlled. VAS and ODI values were significantly improved. DISCUSSION Satisfactory clinical and functional outcomes were achieved in our patients post-operatively. It is recommended that PED plus PPSF can be another alternative for spondylodiscitis. CONCLUSION PED supplementing PPSF offers a valid option in treating spondylodiscitis, as it is minimally invasive, shortens hospital stay, and avoids prolonged bed rest with an optimistic outcome.
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Affiliation(s)
- Kaidi Duan
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Yi Qin
- Dept. of Orthopedics, Zhuhai People’s Hospital, 79 Kangning Road, Zhuhai, China
| | - Jichao Ye
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Wei Zhang
- Dept. of Orthopedics, Xinsteel Center Hospital, Tuanjie West Road, Xinyu, China
| | - Xumin Hu
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Jinlang Zhou
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Liangbin Gao
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Yong Tang
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
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Surgical Management of L5-S1 Spondylodiscitis on Previously Documented Isthmic Spondylolisthesis: Case Report and Review of the Literature. Case Rep Surg 2020; 2020:1408701. [PMID: 32128267 PMCID: PMC7048921 DOI: 10.1155/2020/1408701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/30/2019] [Indexed: 11/18/2022] Open
Abstract
Background Although lumbar isthmic spondylolisthesis is frequent in the Caucasian population, its association with spondylodiscitis is extremely rare. Case Description. The authors reported the case of a 44-year-old patient affected by pyogenic spondylodiscitis on previously documented isthmic spondylolisthesis at the L5-S1 level. The patient was surgically treated by circumferential arthrodesis combining anterior lumbar interbody fusion (ALIF), followed by L4-S1 percutaneous osteosynthesis using the same anesthesia. Appropriate antibiotherapy to methicillin-susceptible Staphylococcus aureus, found on the intraoperative samplings, was then delivered for 3 months, allowing satisfactory evolution on the clinical, biological, and radiological levels. Discussion. This is the first case report of spondylodiscitis affecting an isthmic spondylolisthesis surgically treated by circumferential arthrodesis. In addition to providing large samplings for analysis, it confirms the observed evolution over the past 30 years in modern care history of spondylodiscitis, increasingly including surgical treatment with spinal instrumentation, thus avoiding the need of an external immobilization. Care must nonetheless be exercised in performing the ALIF because of the inflammatory tissue increasing the risk of vascular injury. Conclusion Spondylodiscitis occurring on an L5-S1 isthmic spondylolisthesis can be safely managed by circumferential arthrodesis combining ALIF then percutaneous osteosynthesis in the same anesthesia, obviously followed by appropriate antibiotherapy.
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Farah K, Peyriere H, Graillon T, Prost S, Dufour H, Blondel B, Fuentes S. Minimally invasive posterior fixation and anterior debridement-fusion for thoracolumbar spondylodiscitis: A 40-case series and review of the literature. Neurochirurgie 2019; 66:24-28. [PMID: 31836488 DOI: 10.1016/j.neuchi.2019.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/20/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Pyogenic spondylodiscitis is a rare disease, but incidence is increasing. Reported failure rates following conservative management range from 12% to 18%. The purpose of this study was to determine the safety and efficacy of posterior percutaneous pedicle screw fixation combined with anterior debridement and fusion (ADF) for infective spondylodiscitis in the thoracic and/or lumbar spine. METHODS The retrospective study cohort comprised all patients without neurological deficit who underwent minimally invasive posterior and anterior surgery between April 2008 and April 2016 for thoracic and/or lumbar spondylodiscitis. RESULTS Forty patients were eligible (16 female: 40%). The lumbar region was affected in 31 cases (77.5%). Source of infection was identified in only 22 cases (55%) and bacteriological identification was obtained in 32 cases (80%). Mean hospital stay was 14.8 days (range, 6-39 days). Complete recovery was achieved in 39 patients (97.5%) at 3 months' follow-up. Mean preoperative local kyphosis angle was 16.1o, versus 14o at 1-year (P>0.05). 36 patients (90%) had at least 1 year's follow-up, and fusion was obtained for all these cases. CONCLUSION Two-stage minimally invasive surgery is effective and safe for the treatment of single or two-level thoracolumbar spondylodiscitis. It could be an alternative to conventional open surgery or conservative treatment.
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Affiliation(s)
- K Farah
- Department of neurosurgery, La Timone university hospital, AP-HM, 13005 Marseille, France; Spine Unit, La Timone university hospital, AP-HM, Marseille, France.
| | - H Peyriere
- Department of neurosurgery, La Timone university hospital, AP-HM, 13005 Marseille, France; Spine Unit, La Timone university hospital, AP-HM, Marseille, France
| | - T Graillon
- Department of neurosurgery, La Timone university hospital, AP-HM, 13005 Marseille, France; Spine Unit, La Timone university hospital, AP-HM, Marseille, France
| | - S Prost
- Department of orthopedic surgery, La Timone university hospital, AP-HM, Marseille, France; Spine Unit, La Timone university hospital, AP-HM, Marseille, France
| | - H Dufour
- Department of neurosurgery, La Timone university hospital, AP-HM, 13005 Marseille, France; Spine Unit, La Timone university hospital, AP-HM, Marseille, France
| | - B Blondel
- Department of orthopedic surgery, La Timone university hospital, AP-HM, Marseille, France; Spine Unit, La Timone university hospital, AP-HM, Marseille, France
| | - S Fuentes
- Department of neurosurgery, La Timone university hospital, AP-HM, 13005 Marseille, France; Spine Unit, La Timone university hospital, AP-HM, Marseille, France
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Heary RF, Agarwal N, Agarwal P, Goldstein IM. Surgical Treatment With Thoracic Pedicle Screw Fixation of Vertebral Osteomyelitis With Long-Term Follow-up. Oper Neurosurg (Hagerstown) 2019; 17:443-451. [PMID: 30690618 DOI: 10.1093/ons/opy398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 01/11/2019] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Robert F Heary
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Prateek Agarwal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ira M Goldstein
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Lambert A, Charles YP, Ntilikina Y, Lefebvre N, Hansmann Y, Sauleau EA, Steib JP. Safety and efficacy of percutaneous instrumentation combined with antibiotic treatment in spondylodiscitis. Orthop Traumatol Surg Res 2019; 105:1165-1170. [PMID: 31471258 DOI: 10.1016/j.otsr.2019.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with spondylodiscitis are treated with antibiotics and braces for 6 to 12 weeks. Braces aim to decrease pain and prevent kyphotic deformity due to vertebral body collapse. Percutaneous instrumentation could be an alternative to influence pain and patient's autonomy. PURPOSE The purpose of this study was to analyze back pain, quality of life, sagittal deformity, and complications after percutaneous instrumentation in spondylodiscitis. PATIENTS AND METHODS VAS for back pain, EQ-5D, radiographic sagittal index were assessed retrospectively for 28 patients who had a standardized follow-up at 5 days, 6 weeks, 3 months, 1 and 2 years. Probabilities>0.95 indicated significant changes (Bayesian model). RESULTS VAS was 7.0 preoperatively, 3.2 (day 5), 2.2 (6 weeks), 1.9 (3 months), 1.6 (1 year), 1.4 (2 years): probabilities>0.95 within 6 weeks. EQ-5D was 0.229 preoperatively, 0.563 (6 weeks), 0.687 (3 months), 0.755 (1 year), 0.787 (2 years): probabilities>0.95 within 1 year. Sagittal index was 15.1° preoperatively, 9.6° postoperatively: probability>0.95. Inter-body fusion was: complete 60.7%, partial 17.9%, and nonunion 21.4%. Antibiotic treatment was stopped at 6 weeks in 82.1%, at 3 months in 17.9%, without septic complication. CONCLUSION Percutaneous instrumentation improved pain control, quality of life and prevented kyphosis. Antibiotic treatment was not influenced. Septic complications were not observed. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Arnauld Lambert
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France.
| | - Yann Philippe Charles
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France
| | - Yves Ntilikina
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France
| | - Nicolas Lefebvre
- Service de maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France
| | - Yves Hansmann
- Service de maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France
| | - Erik André Sauleau
- Département de santé publique, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67200 Strasbourg, France
| | - Jean-Paul Steib
- Service de chirurgie du Rachis, hôpitaux universitaires de Strasbourg, 67200 Strasbourg, France
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Hammoud M, Fares Y, Atoui R, Dabboucy B. Burkholderia cepacia as a cause of pyogenic spondylodiscitis in immunocompetent patients: a single-institution case series and literature review. JOURNAL OF SPINE SURGERY 2019; 5:372-377. [PMID: 31663049 DOI: 10.21037/jss.2019.07.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Burkholderia cepacia is an important pathogen of humans in both immunocompromised and hospitalized patients. This uncommon pathogen is established to be the cause of pyogenic spondylodiscitis in only seven cases in the medical literature. Here, we report the cases of four patients who were diagnosed over two years period with Burkholderia cepacia spondylodiscitis and were successfully managed by appropriate antimicrobial treatment after open surgical biopsy was done for debridement and microbiological identification.
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Affiliation(s)
- Maarouf Hammoud
- Department of Neurosurgery, Zahraa University Hospital, Beirut, Lebanon
| | - Youssef Fares
- Department of Neurosurgery, Neuroscience Research Center, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Roula Atoui
- Infectious Disease Department, Zahraa University Hospital, Beirut, Lebanon
| | - Baraa Dabboucy
- Department of Neurosurgery, Faculty of Medicine, Lebanese University, Beirut, Lebanon
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Gregori F, Grasso G, Iaiani G, Marotta N, Torregrossa F, Landi A. Treatment algorithm for spontaneous spinal infections: A review of the literature. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2019; 10:3-9. [PMID: 31000972 PMCID: PMC6469318 DOI: 10.4103/jcvjs.jcvjs_115_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management. Methods: A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus. Results: Literature reveals that on the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of physical, radiological, and microbiological examinations. Microbiological culture samples can be obtained by a percutaneous computed tomography-guided procedure or by an open surgical biopsy. When possible, the samples should be harvested before antibiotic treatment is started. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and failure of conservative treatment. Conclusion: A multidisciplinary approach involving both a spinal surgeon and an infectious disease specialist is necessary to better define the treatment strategy. Based on literature findings, a treatment algorithm for the diagnosis and management of primary spinal infections is proposed.
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Affiliation(s)
- Fabrizio Gregori
- Department of Human Neurosciences, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Giovanni Grasso
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Palermo, Italy
| | - Giancarlo Iaiani
- Department of Tropical and Infectious Diseases, Aou Policlinico Umberto I, Rome, Italy
| | - Nicola Marotta
- Department of Human Neurosciences, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
| | - Fabio Torregrossa
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Palermo, Italy
| | - Alessandro Landi
- Department of Human Neurosciences, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy
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Management of spinal infection: a review of the literature. Acta Neurochir (Wien) 2018; 160:487-496. [PMID: 29356895 PMCID: PMC5807463 DOI: 10.1007/s00701-018-3467-2] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/08/2018] [Indexed: 12/17/2022]
Abstract
Spinal infection (SI) is defined as an infectious disease affecting the vertebral body, the intervertebral disc, and/or adjacent paraspinal tissue and represents 2–7% of all musculoskeletal infections. There are numerous factors, which may facilitate the development of SI including not only advanced patient age and comorbidities but also spinal surgery. Due to the low specificity of signs, the delay in diagnosis of SI remains an important issue and poor outcome is frequently seen. Diagnosis should always be supported by clinical, laboratory, and imaging findings, magnetic resonance imaging (MRI) remaining the most reliable method. Management of SI depends on the location of the infection (i.e., intraspinal, intervertebral, paraspinal), on the disease progression, and of course on the patient’s general condition, considering age and comorbidities. Conservative treatment mostly is reasonable in early stages with no or minor neurologic deficits and in case of severe comorbidities, which limit surgical options. Nevertheless, solely medical treatment often fails. Therefore, in case of doubt, surgical treatment should be considered. The final result in conservative as well as in surgical treatment always is bony fusion. Furthermore, both options require a concomitant antimicrobial therapy, initially applied intravenously and administered orally thereafter. The optimal duration of antibiotic therapy remains controversial, but should never undercut 6 weeks. Due to a heterogeneous and often comorbid patient population and the wide variety of treatment options, no generally applicable guidelines for SI exist and management remains a challenge. Thus, future prospective randomized trials are necessary to substantiate treatment strategies.
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Viezens L, Schaefer C, Helmers R, Vettorazzi E, Schroeder M, Hansen-Algenstaedt N. Spontaneous Pyogenic Spondylodiscitis in the Thoracic or Lumbar Spine: A Retrospective Cohort Study Comparing the Safety and Efficacy of Minimally Invasive and Open Surgery Over a Nine-Year Period. World Neurosurg 2017; 102:18-27. [PMID: 28286275 DOI: 10.1016/j.wneu.2017.02.129] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Pyogenic spondylodiscitis is a rare disease, but its incidence is increasing. Over the last decade, spinal surgery has been modified to become minimally invasive. In degenerative spinal disorders, such minimally invasive surgery (MIS) reduces blood loss, muscular trauma, and the hospital stay. However, it is not known whether MIS also confers these benefits to patients with pyogenic spondylodiscitis. This retrospective cohort study compared the safety and efficacy of MIS and the conventional open surgical procedure in patients with pyogenic spondylodiscitis. METHODS The study cohort consisted of all consecutive patients who underwent surgery for thoracic or lumbar pyogenic spondylodiscitis that was not caused by previous surgery or tuberculosis in our tertiary-care institution between January 2003 and December 2011. RESULTS Of the 148 eligible patients, 75 and 73 underwent MIS and open surgery, respectively. The 2 groups did not differ in terms of age, body mass index, American Society of Anaesthesiologists score, comorbidities, septic disease, or preoperative neurologic deficit. The 2 methods were associated with similar postoperative stays in the intensive care unit, overall hospital stays, complication rates, and postoperative survival. However, MIS was associated with a significantly shorter operating time, a lower perioperative need for blood products, and, as expected, an increased intraoperative fluoroscopy duration. CONCLUSIONS Our 9-year experience suggests that MIS is safe and effective for spontaneous pyogenic thoracic and lumbar spondylodiscitis.
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Affiliation(s)
- Lennart Viezens
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Trauma-, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany.
| | - Christian Schaefer
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Spine Surgery, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Rachel Helmers
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Schroeder
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils Hansen-Algenstaedt
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Spine Surgery, Parkklinik Manhagen, Hamburg, Germany
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Posterior Only Approach for Lumbar Pyogenic Spondylitis With Short Instrumentation and Prolonged Suction Drainage. Spine (Phila Pa 1976) 2016; 41:E1022-E1029. [PMID: 26977850 DOI: 10.1097/brs.0000000000001566] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A single-institution, single-surgeon retrospective review. OBJECTIVE To assess the efficacy of posterior only approach with short instrumentation and prolonged suction drainage in managing lumbar pyogenic spondylitis. SUMMARY OF BACKGROUND DATA Several methods of posterior surgical treatment for pyogenic spondylitis have been reported, there have been few reports regarding the efficacy of posterior only approach with short instrumentation including even inflamed segment. METHODS Thirty-three patients with lumbar pyogenic spondylitis who underwent posterior decompression and lumbar interbody fusion with short instrumentation including the inflamed segment and catheter drainage were enrolled. Clinically infection control (erythrocyte sedimentation rate and C-reactive protein normalization time) and onset of ambulation were reviewed. Moreover, achievement of fusion and changes of sagittal alignment were investigated radiologically. RESULTS In all 33 cases, infection was controlled successfully without any recurrence. There was no breakage of implant. Postoperative interval to normalization of erythrocyte sedimentation rate was average 69.4 days and C-reactive protein was 25.4 days, respectively. Ambulation was started at average 5.8 postoperative days. Successful interbody fusion was confirmed radiologically in all the cases at a mean of 5.4 months. Sagittal angle of fixed segment was average 6.9 degrees of lordosis before operation, which became more lordotic to 11.5 degrees just after operation, but decreased to 4.7 degrees of lordosis at the final follow up. Actually final sagittal alignment was almost same as preoperative status (P = 0.24). CONCLUSION By achieving favorable clinical and radiological results, short instrumentation and prolonged suction drainage with posterior only approach seemed to be an effective method in managing lumbar pyogenic spondylitis. LEVEL OF EVIDENCE 3.
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28
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Evaluation of surgical strategy of conventional vs. percutaneous robot-assisted spinal trans-pedicular instrumentation in spondylodiscitis. J Robot Surg 2016; 11:17-25. [DOI: 10.1007/s11701-016-0597-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
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29
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Pourtaheri S, Issa K, Stewart T, Shafa E, Ajiboye R, Buerba RA, Lord E, Hwang K, Mangels D, Emami A. Comparison of Instrumented and Noninstrumented Surgical Treatment of Severe Vertebral Osteomyelitis. Orthopedics 2016; 39:e504-8. [PMID: 27135455 DOI: 10.3928/01477447-20160427-07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 11/11/2015] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare the outcomes of instrumented versus noninstrumented (decompression) surgical treatment of vertebral osteomyelitis. The study population included 104 patients with spinal osteomyelitis who were treated at the authors' institution between 2004 and 2012. This included 62 men and 42 women who underwent either instrumented (n=57) or noninstrumented (n=47) surgery. Mean patient age was 59 years, and mean follow-up was 38 months (range, 12-78 months). Specifically, the following criteria were assessed: mortality rates, infection clearance rates, clinical outcomes measured by Oswestry Disability Index (ODI), mean length of stay, and baseline differences between the 2 cohorts. Although patients in the instrumented cohort had more instability, more neurologic symptoms, and larger volume infection, they had similar clearance of infection (54% vs 42.5%; odds ratio [OR], 1.55; 95% confidence interval [CI], 0.61-3.9; P=.35), mortality rate (9% vs 17%; OR, 0.47; 95% CI, 0.14-1.54; P=.21), and ODI scores (40 vs 45 points; P=.32) compared with patients in the noninstrumented group. However, mean length of stay (19 vs 13 days; P=.02) was significantly higher for patients in the instrumented group. Even in more severe cases of vertebral osteomyelitis, instrumentation resulted in comparable outcomes to decompression. [Orthopedics. 2016; 39(3):e504-e508.].
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Percutaneous Transpedicular Interbody Fusion Technique in Percutaneous Pedicle Screw Stabilization for Pseudoarthrosis Following Pyogenic Spondylitis. Asian Spine J 2016; 10:343-8. [PMID: 27114777 PMCID: PMC4843073 DOI: 10.4184/asj.2016.10.2.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 07/25/2015] [Accepted: 08/14/2015] [Indexed: 11/11/2022] Open
Abstract
This report introduces a percutaneous transpedicular interbody fusion (PTPIF) technique in posterior stabilization using percutaneous pedicle screws (PPSs). An 81-year-old man presented with pseudoarthrosis following pyogenic spondylitis 15 months before. Although no relapse of infection was found, he complained of obstinate low back pain and mild neurological symptoms. Radiological evaluations showed a pseudoarthrosis following pyogenic spondylitis at T11–12. Posterior stabilization using PPSs from Th9 to L2 and concomitant PTPIF using autologous iliac bone graft at T11–12 were performed. Low back pain and neurological symptoms were immediately improved after surgery. A solid interbody fusion at T11–12 was completed 9 months after surgery. The patient had no restriction of daily activity and could play golf at one year after surgery. PTPIF might be a useful option for perform segmental fusion in posterior stabilization using PPSs.
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Pyogenic lumbar spondylodiscitis treated with transforaminal lumbar interbody fusion: safety and outcomes. INTERNATIONAL ORTHOPAEDICS 2015; 40:1163-70. [PMID: 26711446 DOI: 10.1007/s00264-015-3063-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/27/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE Our aim was to study the safety and outcomes of posterior instrumentation and transforaminal lumbar interbody fusion (TLIF) for treating pyogenic lumbar spondylodiscitis. METHODS Retrospective analysis was performed on prospectively collected data of 27 consecutive cases of lumbar pyogenic spondylodiscitis treated with posterior instrumentation and TLIF between January 2009 and December 2012. Cases were analysed for safety, radiological and clinical outcomes of transforaminal interbody fusion using bone graft ± titanium cages. Interbody metallic cages with bone graft were used in 17 cases and ten cases used only bone graft. Indications for surgical treatment were failed conservative management in 17, neurodeficit in six and significant bony destruction in four. RESULTS There were no cases reporting cage migration, loosening, pseudoarthrosis or recurrence of infection at a mean follow-up of 30 months. Clinical outcomes were assessed using Kirkaldy-Willis criteria, which showed 14 excellent, nine good, three fair and one poor result. Mean focal deformity improved with the use of bone graft ± interbody cages, and the deformity correction was maintained at final follow-up. Mean pre-operative focal lordosis for the graft group was 8.5° (2-16.5°), which improved to 10.9 °(3.3-16°); mean pre-operative focal lordosis in the group treated with cages was 6.7 °(0-15°), which improved to 7°(0-15°) . CONCLUSION TLIFs with cages in patients with pyogenic lumbar spondylodiscitis allows for acceptable clearance of infection, satisfactory deformity correction with low incidence of cage migration, loosening and infection recurrence.
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Mazur MD, Ravindra VM, Dailey AT, McEvoy S, Schmidt MH. Rigid Posterior Lumbopelvic Fixation without Formal Debridement for Pyogenic Vertebral Diskitis and Osteomyelitis Involving the Lumbosacral Junction: Technical Report. Front Surg 2015; 2:47. [PMID: 26442278 PMCID: PMC4585130 DOI: 10.3389/fsurg.2015.00047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/31/2015] [Indexed: 12/01/2022] Open
Abstract
Background Pelvic fixation with S2-alar-iliac (S2AI) screws can increase the rigidity of a lumbosacral construct, which may promote bone healing, improve antibiotic delivery to infected tissues, and avoid L5–S1 pseudarthrosis. Purpose To describe the use of single-stage posterior fixation without debridement for the treatment of pyogenic vertebral diskitis and osteomyelitis (PVDO) at the lumbosacral junction. Study design Technical report. Methods We describe the management of PVDO at the lumbosacral junction in which the infection invaded the endplates, disk space, vertebrae, prevertebral soft tissues, and epidural space. Pedicle involvement precluded screw fixation at L5. Surgical management consisted of a single-stage posterior operation with rigid lumbopelvic fixation augmented with S2-alar-iliac screws and without formal debridement of the infected area, followed by long-term antibiotic treatment. Results At 2-year follow-up, successful fusion and eradication of the infection were achieved. Conclusion PVDO at the lumbosacral junction may be treated successfully using rigid posterior-only fixation without formal debridement combined with antibiotic therapy.
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Affiliation(s)
- Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Sara McEvoy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
| | - Meic H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah , Salt Lake City, UT , USA
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Extreme lateral interbody fusion with posterior instrumentation for spondylodiscitis. J Clin Neurosci 2015; 22:1758-61. [PMID: 26138052 DOI: 10.1016/j.jocn.2015.05.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 05/22/2015] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to evaluate our initial experience utilizing extreme lateral interbody fusion (XLIF; NuVasive, San Diego, CA, USA) with percutaneous posterior instrumentation to treat 11 spondylodiscitis patients between January 2011 and February 2014. Although medical management is the first line treatment for spondylodiscitis, many patients fail antibiotic therapy and bracing, or present with instability, neurologic deficits, or sepsis, requiring operative debridement and stabilization. High rates of fusion and infection clearance have been reported with anterior lumbar interbody fusion (ALIF), but this approach requires a morbid exposure, associated with non-trivial rates of vascular and peritoneal complications. XLIF is an increasingly popular interbody fusion technique which utilizes a fast and minimally invasive approach, sparing the anterior longitudinal ligament, and allowing sufficient visualization of the intervertebral discs and bodies to debride and place a large, lordotic cage. The outcome measures for this study included lumbar lordosis, sagittal balance, subsidence, fusion, pain, neurological deficit, and microbiology/laboratory evidence of infection. The mean follow-up time was 9.3 months. All patients had improvements in pain and neurological symptoms. The mean lordosis change was 11.0°, from 23.1° preoperatively to 34.0° postoperatively. Fusion was confirmed with CT scans in five of six patients. At the last follow-up, all patients had normalization of inflammatory markers, no symptoms of infection, and none required repeat surgical treatment for spondylodiscitis. XLIF with percutaneous posterior instrumentation is a minimally invasive technique with reduced morbidity for lumbar spine fusion which affords adequate exposure to the vertebral bodies and discs to aggressively debride necrotic and infected tissue. This study suggests that XLIF may be a safe and effective alternative to ALIF for the treatment of spondylodiscitis.
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Accidental Durotomy in Minimally Invasive Transforaminal Lumbar Interbody Fusion: Frequency, Risk Factors, and Management. ScientificWorldJournal 2015; 2015:532628. [PMID: 26075294 PMCID: PMC4449940 DOI: 10.1155/2015/532628] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 01/02/2015] [Indexed: 11/18/2022] Open
Abstract
Purpose. To assess the frequency, risk factors, and management of accidental durotomy in minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Methods. This single-center study retrospectively investigates 372 patients who underwent MIS TLIF and were mobilized within 24 hours after surgery. The frequency of accidental durotomies, intraoperative closure technique, body mass index, and history of previous surgery was recorded. Results. We identified 32 accidental durotomies in 514 MIS TLIF levels (6.2%). Analysis showed a statistically significant relation of accidental durotomies to overweight patients (body mass index ≥25 kg/m2; P = 0.0493). Patient age older than 65 years tended to be a positive predictor for accidental durotomies (P = 0.0657). Mobilizing patients on the first postoperative day, we observed no durotomy-associated complications. Conclusions. The frequency of accidental durotomies in MIS TLIF is low, with overweight being a risk factor for accidental durotomies. The minimally invasive approach seems to minimize durotomy-associated complications (CSF leakage, pseudomeningocele) because of the limited dead space in the soft tissue. Patients with accidental durotomy can usually be mobilized within 24 hours after MIS TLIF without increased risk. The minimally invasive TLIF technique might thus be beneficial in the prevention of postoperative immobilization-associated complications such as venous thromboembolism. This trial is registered with DRKS00006135.
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Lin TY, Tsai TT, Lu ML, Niu CC, Hsieh MK, Fu TS, Lai PL, Chen LH, Chen WJ. Comparison of two-stage open versus percutaneous pedicle screw fixation in treating pyogenic spondylodiscitis. BMC Musculoskelet Disord 2014; 15:443. [PMID: 25519761 PMCID: PMC4300775 DOI: 10.1186/1471-2474-15-443] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 12/15/2014] [Indexed: 01/11/2023] Open
Abstract
Background Percutaneous pedicle screw instrumentation is a minimally invasive surgical technique; however, the effects of using percutaneous pedicle screw fixation in treating patients with spinal infections have not yet been well demonstrated. The aim of this study, therefore, was to determine whether percutaneous posterior pedicle screw instrumentation is superior to the traditional open approach in treating pyogenic spondylodiscitis. Methods We retrospectively reviewed data for 45 patients treated for pyogenic spondylodiscitis with anterior debridement and interbody fusion followed by a second-stage procedure involving either traditional open posterior pedicle screw fixation or percutaneous posterior pedicle screw fixation. Twenty patients underwent percutaneous fixation and 25 patients underwent open fixation. Demographic, operative, and perioperative data were collected and analyzed. Results The average operative time for the percutaneous procedure was 102.5 minutes, while the average time for the open procedure was 129 minutes. The average blood loss for the percutaneous patients was 89 ml versus a 344.8 ml average for the patients in the open group. Patients who underwent the minimally invasive surgery had lower visual analogue scale scores and required significantly less analgesia afterwards. After two years of follow-up, neither recurrent infection nor intraoperative complications, such as wound infection or screw loosening, were found in the percutaneous group. Moreover, there was no significant difference in outcome between the two groups in terms of Oswestry Disability Index scores. Conclusions Anterior debridement and interbody fusion with bone grafting followed by minimally invasive percutaneous posterior instrumentation is an alternative treatment for pyogenic spondylodiscitis which can result in less intraoperative blood loss, shorter operative time, and reduced postoperative pain with no adverse effect on infection control. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-443) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, No, 5, Fusing Street, Guishan Township, Taoyuan 333, Taiwan.
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Spondylodiscitis by drug-multiresistant bacteria: a single-center experience of 25 cases. Spine J 2014; 14:2826-34. [PMID: 24704675 DOI: 10.1016/j.spinee.2014.03.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 02/03/2014] [Accepted: 03/26/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although the incidence of pyogenic spinal infections is increasing, the ideal treatment of spondylodiscitis is still a controversially discussed issue. Furthermore, the proportion of multiresistant bacteria in spondylodiscitis is increasing, and treatment recommendations or reported results are missing for this especially difficult subset of patients. PURPOSE The aim of this study is to evaluate the surgical outcome and the postoperative antibacterial treatment regime. STUDY DESIGN Retrospective case series. PATIENT SAMPLE Patients treated for a spondylodiscitis from multiresistant bacteria at our department between 2006 and 2011. METHODS Data were gathered through review of patients' case notes, relevant imaging, and electronic records. Magnetic resonance imaging of the whole spine including gadolinium (Gd)-enhanced T1 sequences and computed tomography scans of the affected regions were obtained in all cases. OUTCOME MEASURES C-reactive protein (CRP) and complete blood cell count were analyzed in all cases using routine laboratory techniques. Neurologic deficits were classified according to the American Spinal Injury Association (ASIA) impairment scale. RESULTS Twenty-five patients were identified (15 gram-positive and 10 gram-negative drug-multiresistant bacteria). The mean age at presentation was 66 years, and 14 patients were male (56%). All patients presented with pain, and a neurologic deficit was present in 11 (44%) cases. An epidural abscess was found in 11 (44%) cases. At admission, CRP was elevated in all cases with a mean of 13±9.2 mg/dL. The main source of infection was previous spine surgery (36%). All patients in this series underwent surgical debridement of the infection and instrumentation of the spine. Postoperative intravenous antibiotics were administered for 19±8.6 days followed by 3±0.3 months of oral antibiotic therapy. Eradication of the infection was achieved ultimately in all surviving patients. Out of 11 patients with neurologic deficits, 4 had a full recovery, 4 improved incompletely, and 3 remained unchanged after surgery. CONCLUSIONS Staged surgical immobilization and instrumentation and optimal debridement at the interdiscal space and spinal canal is a reliable approach to achieve complete healing of spinal infection with multiresistant bacteria. A period of intravenous antibiotic therapy of 2 to 3 weeks followed by a 3-month oral antibiotic therapy seems appropriate for most cases.
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Schomacher M, Finger T, Koeppen D, Süss O, Vajkoczy P, Kroppenstedt S, Cabraja M. Application of titanium and polyetheretherketone cages in the treatment of pyogenic spondylodiscitis. Clin Neurol Neurosurg 2014; 127:65-70. [PMID: 25459245 DOI: 10.1016/j.clineuro.2014.09.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 08/25/2014] [Accepted: 09/28/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Surgical treatment of a pyogenic spondylodiscitis (PSD) involves a fixation and debridement of the affected segment combined with a specific antibiotic therapy. To achieve a proper stability and to avoid pseudarthrosis and kyphotic malposition many surgeons favour the interposition of an anterior graft. Besides autologous bone grafts titanium (TTN) cages have gained acceptance in the treatment of PSD. Polyetheretherketone (PEEK) cages have a more favourable modulus of elasticity than TTN. We compared both cage types. Primary endpoints were the rate of reinfection and radiological results. METHODS From 2004 to 2013 51 patients underwent surgery for PSD with fixation and TTN or PEEK cage-implantation. While lumbar patients underwent a partial discectomy by the posterior approach, discs of the cervical and thoracic patients had been totally removed from anterior. Clinical and radiological parameters were assessed in 37 eligible patients after a mean of 20.4 months. 21 patients received a PEEK- and 16 patients a TTN-cage. RESULTS A reinfection after surgery and 3 months of antibiotic therapy was not observed. Solid arthrodesis was found in 90.5% of the PEEK-group and 100% of the TTN-group. A segmental correction could be achieved in both groups. Nonetheless, a cage subsidence was observed in 70.3% of all cases. Comparison of radiological results revealed no differences between both groups. CONCLUSIONS A debridement and fixation with anterior column support in combination with an antibiotic therapy appear to be the key points for successful treatment of PSD. The application of TTN- or PEEK-cages does not appear to influence the radiological outcome or risk of reinfection, neither does the extent of disc removal in this clinical subset.
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Affiliation(s)
- Markus Schomacher
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Finger
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Koeppen
- Department of Neurosurgery, Bundeswehrkrankenhaus Koblenz, Koblenz, Germany
| | - Olaf Süss
- Department of Spine Surgery and Neurotraumatology, DRK Kliniken Westend, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Kroppenstedt
- Department of Orthopedic Surgery, Sana Kliniken Sommerfeld, Kremmen, Germany
| | - Mario Cabraja
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Nasto LA, Colangelo D, Mazzotta V, Di Meco E, Neri V, Nasto RA, Fantoni M, Pola E. Is posterior percutaneous screw-rod instrumentation a safe and effective alternative approach to TLSO rigid bracing for single-level pyogenic spondylodiscitis? Results of a retrospective cohort analysis. Spine J 2014; 14:1139-46. [PMID: 24139231 DOI: 10.1016/j.spinee.2013.07.479] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 06/21/2013] [Accepted: 07/25/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Currently, treatment for patients diagnosed with noncomplicated (ie, known infectious agent, no neurologic compromise, and preserved spinal stability) pyogenic spondylodiscitis (PS) is based on intravenous antibiotics and rigid brace immobilization. Since January 2010, we started offering our patients percutaneous posterior screw-rod instrumentation as an alternative approach to rigid bracing. Supposed benefits of posterior percutaneous instrumentation over rigid bracing are earlier free mobilization, increased comfort, and faster recovery. PURPOSE To evaluate safety and effectiveness of posterior percutaneous spinal instrumentation for single-level PS and compare clinical and quality-of-life outcomes with standard thoracolumbosacral orthosis (TLSO) rigid bracing. STUDY DESIGN/SETTING Retrospective observational cohort study. PATIENT SAMPLE Twenty-seven patients consecutively diagnosed with single-level noncomplicated lower thoracic or lumbar PS from January 2010 to December 2011. OUTCOME MEASURES Healing rate, healing time, and changes in segmental kyphosis Cobb angle were compared in the two treatment groups. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count at regular time points until complete healing were also obtained. Self-report measures included Visual Analog Scale (VAS), Short-Form 12 (SF-12), and EuroQol five-dimension (EQ-5D) questionnaires. METHODS At enrollment, patients were offered to choose between 24/7 TLSO rigid bracing for 3 to 4 months and bridging posterior percutaneous screw-rod instrumentation followed by soft bracing for 4 weeks after surgery. All patients underwent antibiotic therapy accordingly to isolated infectious agents. Patients were seen in the clinic at 1, 3, 6, and 9 months, and ESR, CRP, complete blood count, VAS, SF-12, and EQ-5D questionnaires were obtained. Segmental kyphosis was measured at diagnosis and at 9 months follow-up. Two-way repeated-measures analysis of variance was used to assess group and time differences across time points. RESULTS Fifteen patients chose conservative treatment, whereas 12 patients chose surgical treatment. Complete infection healing was achieved in all patients with no significant differences in healing time (p<.366). C-reactive protein and ESR levels decreased in both groups accordingly with positive response to therapy with no significant differences. Surgically treated patients had significantly lower VAS scores at 1 month (2.76±0.80 vs. 5.20±1.21, p<.001) and 3 months (2.31±0.54 vs. 2.85±0.54, p<.016) post-diagnosis over TLSO patients. Moreover, surgery patients also showed steeper and statistically significant improvements in SF-12 scores over TLSO patients at 1, 3, and 6 months post-diagnosis (p<.012); no significant differences were detected at the other time points. EuroQol five-dimension index was significantly higher in surgery patients at 1 month (0.764±0.043 vs. 0.458±0.197, p<.001) and 3 months (0.890±0.116 vs. 0.688±0.142, p<.001); no significant changes were observed in segmental pre- and posttreatment kyphosis between the two groups. No instrumentation-related complications were observed in any patient. CONCLUSIONS Posterior percutaneous spinal instrumentation is a safe, feasible, and effective procedure in relieving pain, preventing deformity, and neurologic compromise in patients affected by noncomplicated lower thoracic (T9-T12) or lumbar PS. Posterior instrumentation did not offer any advantage in healing time over TLSO rigid bracing because infection clearance is strongly dependent on proper antibiotic therapy. Nevertheless, surgical stabilization was associated with faster recovery, lower pain scores, and improved quality of life compared with TLSO conservative treatment at 1, 3, and 6 months after treatment.
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Affiliation(s)
- Luigi A Nasto
- Division of Spine Surgery, Department of Orthopaedics and Traumatology, Catholic University of Rome, "A. Gemelli" University Hospital, l.go Agostino Gemelli 8, 00168 Rome, Italy
| | - Debora Colangelo
- Division of Spine Surgery, Department of Orthopaedics and Traumatology, Catholic University of Rome, "A. Gemelli" University Hospital, l.go Agostino Gemelli 8, 00168 Rome, Italy
| | - Valentina Mazzotta
- Institute of Infectious Diseases, Catholic University of Rome, "A. Gemelli" University Hospital, l.go Agostino Gemelli 8, 00168 Rome, Italy
| | - Eugenia Di Meco
- Institute of Infectious Diseases, Catholic University of Rome, "A. Gemelli" University Hospital, l.go Agostino Gemelli 8, 00168 Rome, Italy
| | - Valentina Neri
- Department of Medicine, Laboratory of Vascular Biology and Genetics, Catholic University of Rome, "A. Gemelli" University Hospital, l.go Agostino Gemelli 8, 00168 Rome, Italy
| | - Riccardo A Nasto
- Department of Medicine, Laboratory of Vascular Biology and Genetics, Catholic University of Rome, "A. Gemelli" University Hospital, l.go Agostino Gemelli 8, 00168 Rome, Italy
| | - Massimo Fantoni
- Institute of Infectious Diseases, Catholic University of Rome, "A. Gemelli" University Hospital, l.go Agostino Gemelli 8, 00168 Rome, Italy
| | - Enrico Pola
- Division of Spine Surgery, Department of Orthopaedics and Traumatology, Catholic University of Rome, "A. Gemelli" University Hospital, l.go Agostino Gemelli 8, 00168 Rome, Italy.
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Shiban E, Janssen I, Wostrack M, Krieg SM, Ringel F, Meyer B, Stoffel M. A retrospective study of 113 consecutive cases of surgically treated spondylodiscitis patients. A single-center experience. Acta Neurochir (Wien) 2014; 156:1189-96. [PMID: 24671549 DOI: 10.1007/s00701-014-2058-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 03/07/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Recommendations for the operative treatment of spondylodiscitis are still a controversial issue. METHODS A retrospective review identified 113 consecutive patients who underwent surgical debridement and instrumentation for spondylodiscitis between 2006 and 2010 at our department. RESULTS The mean age at presentation was 65 years; 78 patients were male (69 %). Distribution of the inflammation was lumbar in 68 (60 %), thoracic in 19 (17 %) and cervical in 20 (18 %) cases. Six patients (5 %) had two concomitant non-contiguous spondylodiscitis foci in different segments of the spine. Epidural abscess was found in 33 patients (29 %). One hundred four patients (92 %) had pain. Neurological deficit was found in 40 patients (35 %). In the thoracic and lumbar cases, dorsal instrumentation alone was considered sufficient in 26 cases; additional interbody fusion from the posterior was performed in 44 cases. A 360° instrumentation was performed in 22 cases. In the cervical cases, only ventral spondylodesis and plating were performed in eight cases, only dorsal instrumentation in five and 360° instrumentation in seven. Postoperative intravenous antibiotics were administered for 14.4 ± 9.3 (mean ± SD) days followed by 3.2 ± 0.8 (mean ± SD) months of oral antibiosis. Complete healing of the inflammation was achieved in 111 (98 %) cases. Two patients died because of septic shock, both with fulminant endocarditis. Pain resolved in all cases. Neurological deficits were completely resolved in 20 patients, and 14 patients had a partial recovery. CONCLUSION The results of our retrospective study show that surgical treatment of spondylodiscitis with a staged surgical approach (if needed) and a short 1-2-week period of intravenous antibiotics followed by 3 months of oral antibiotics is appropriate for most patients in whom conservative treatment has failed or is not advisable. Furthermore, surgical treatment of newly diagnosed spondylodiscitis might be recommended as an initial treatment option in many cases. Thereby the choice of fusion material (autologous bone, titanium, PEEK) seems less important.
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Percutaneous Posterior Instrumentation Followed by Direct Lateral Interbody Fusion for Lumbar Infectious Spondylitis. ACTA ACUST UNITED AC 2013; 26:E95-100. [DOI: 10.1097/bsd.0b013e31826eaf56] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Fushimi K, Miyamoto K, Fukuta S, Hosoe H, Masuda T, Shimizu K. The surgical treatment of pyogenic spondylitis using posterior instrumentation without anterior debridement. ACTA ACUST UNITED AC 2012; 94:821-4. [DOI: 10.1302/0301-620x.94b6.28632] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There have been few reports regarding the efficacy of posterior instrumentation alone as surgical treatment for patients with pyogenic spondylitis, thus avoiding the morbidity of anterior surgery. We report the clinical outcomes of six patients with pyogenic spondylitis treated effectively with a single-stage posterior fusion without anterior debridement at a mean follow-up of 2.8 years (2 to 5). Haematological data, including white cell count and level of C-reactive protein, returned to normal in all patients at a mean of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion between the infected vertebrae was observed in five patients at a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining patient having partial union. Severe back pain was immediately reduced following surgery and the activities of daily living showed a marked improvement. Methicillin-resistant Staphylococcus aureus was detected as the causative organism in four patients. Single-stage posterior fusion may be effective in patients with pyogenic spondylitis who have relatively minor bony destruction.
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Affiliation(s)
- K. Fushimi
- Gifu University Graduate School of Medicine, Department
of Orthopaedic Surgery, Yanagido 1-1, Gifu
City, Gifu, 501-1194, Japan
| | - K. Miyamoto
- Gifu University Graduate School of Medicine, Department
of Reconstructive Surgery for Spine, Bone, and
Joints, Yanagido 1-1, Gifu
City, Gifu, 501-1194, Japan
| | - S. Fukuta
- Gifu University Graduate School of Medicine, Department
of Orthopaedic Surgery, Yanagido 1-1, Gifu
City, Gifu, 501-1194, Japan
| | - H. Hosoe
- Gifu University Graduate School of Medicine, Department
of Orthopaedic Surgery, Yanagido 1-1, Gifu
City, Gifu, 501-1194, Japan
| | - T. Masuda
- Gifu University Graduate School of Medicine, Department
of Orthopaedic Surgery, Yanagido 1-1, Gifu
City, Gifu, 501-1194, Japan
| | - K. Shimizu
- Gifu University Graduate School of Medicine, Department
of Orthopaedic Surgery, Yanagido 1-1, Gifu
City, Gifu, 501-1194, Japan
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Perioperative course and accuracy of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle screw placement. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:860-8. [PMID: 21384205 PMCID: PMC3099153 DOI: 10.1007/s00586-011-1729-2] [Citation(s) in RCA: 249] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Accepted: 02/23/2011] [Indexed: 10/29/2022]
Abstract
Robotic-guided and percutaneous pedicle screw placement are emerging technologies. We here report a retrospective cohort analysis comparing conventional open to open robotic-guided and percutaneous robotic-guided pedicle screw placement. 112 patient records and CT scans were analyzed concerning the intraoperative and perioperative course. 35 patients underwent percutaneous, 20 open robotic-guided and 57 open conventional pedicle screw placement. 94.5% of robot-assisted and 91.4% of conventionally placed screws were found to be accurate. Percutaneous robotic and open robotic-guided subgroups did not differ obviously. Average X-ray exposure per screw was 34 s in robotic-guided compared to 77 s in conventional cases. Subgroup analysis indicates that percutaneously operated patients required less opioids, had a shorter hospitalization and lower rate of adverse events in the perioperative period. The use of robotic guidance significantly increased accuracy of screw positioning while reducing the X-ray exposure. Patients seem to have a better perioperative course following percutaneous procedures.
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Blondel B, Fuentes S, Pech-Gourg G, Metellus P, Dufour H. [Minimally invasive osteosynthesis in septic conditions]. Neurochirurgie 2011; 57:15-20. [PMID: 21333311 DOI: 10.1016/j.neuchi.2011.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2010] [Accepted: 12/15/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Management of pyogenic spondylodiscitis in adults remains controversial. The aim of this study was to evaluate the results of a minimally invasive method for deformity correction and stabilization of these lesions with percutaneous osteosynthesis. METHODS Ten patients were included in this study and treated with a two-step procedure: posterior percutaneous osteosynthesis completed by complementary intervertebral grafting via an anterior access. Postoperative evaluation was clinical and radiological with measurement of local sagittal deformity and restitution of vertebral body height. RESULTS In this series, bacteriologic identification was possible and pain was controlled in every case. On postoperative evaluation, the implants were always properly positioned. The mean local sagittal deformation was +2.1° preoperatively and -8.4° postoperatively. The mean increase in vertebral body height was measured at 8mm postoperatively. At the last follow-up, a moderate loss of correction was noted (mean: 2° and 3mm) and all patients but one showed solid bony fusion. CONCLUSION Percutaneous osteosynthesis in septic conditions in association with an anterior graft provides satisfactory clinical and radiographic results. It provides a valuable alternative for deformity correction and spinal stabilization with a minimally invasive access in patients with comorbidities.
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Affiliation(s)
- B Blondel
- Service de neurochirurgie, hôpital de la Timone, AP-HM, 249 rue Saint-Pierre, Marseille, France
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Abstract
Spinal infection may involve the vertebrae, the intervertebral discs, and the adjacent intraspinal and paraspinal soft tissues. It often starts with subtle and insidious clinical signs and symptoms and may development to a debilitating and even life threatening disease. Spinal infections occur with increasing incidence and are nowadays a disease of everyday's practice for physicians treating spinal disorders. Traditionally, conservative treatment consisting of antibiosis and immobilisation is considered the first tier therapy. However, due to a considerably high rate of vertebral column instability or neurological impairment caused by the infected tissue, comprehensive experience with surgical measures have been acquired over the last decades. Thanks to tremendous improvements of surgical implants and techniques, surgical treatment has already begun to challenge conservative treatment to eventually become the first tier therapy for spinal infections in the future. This review seeks to give an overview of epidemiology, pathogenesis, diagnostic evaluation, and current nonsurgical and surgical therapy of spinal infections on the basis of the existing literature, which consists largely of retrospectively acquired data of single-centre experience with sample sizes of less than 100 patients treated with individually defined indications and treatment algorithms, and followed with various outcome parameters.
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Affiliation(s)
- M Stoffel
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität Munchen, Munich, Germany
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Septic hematogenous lumbar spondylodiscitis in elderly patients with multiple risk factors: efficacy of posterior stabilization and interbody fusion with iliac crest bone graft. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:1720-7. [PMID: 20495933 DOI: 10.1007/s00586-010-1448-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 02/27/2010] [Accepted: 05/09/2010] [Indexed: 12/19/2022]
Abstract
The conservative and operative treatment strategies of hematogenous spondylodiscitis in septic patients with multiple risk factors are controversial. The present series demonstrates the outcome of 18 elderly patients (median age, 72 years) with septic hematogenous spondylodiscitis and intraspinal abscess treated with microsurgical decompression and debridement of the infective tissue, followed by posterior stabilization and interbody fusion with iliac crest bone graft in one or two lumbar segments. The majority of the patients were unsuccessfully treated with intravenous antibiotics prior to the operation. Antibiotic therapy was continued for more than 6 weeks postoperatively. Morbidity and early mortality amounted to 50 and 17%, respectively. Three patients died in the hospital from internal complications after an initial postoperative improvement of the inflammatory clinical signs and laboratory parameters. Fifteen patients recovered from the spinal infection. Three of them died several months after discharge (cerebral hemorrhage, malignancy and unknown cause). Twelve patients had excellent or good outcomes during the follow-up period of at least 1 year. The series shows that operative decompression and eradication of the intraspinal and intervertebral infective tissue with fusion and stabilization via a posterior approach is possible in septic patients with multiple risk factors and leads to good results in those patients, who survive the initial severe stage of the septic disease. However, the morbidity and mortality suggest that this surgical treatment is not the therapy of first choice in high-risk septic patients, but may be considered in patients when conservative management has failed.
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