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

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

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSIONS

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

Clinical results of a lamina with spinous process and an iliac graft as bone grafts in the surgical treatment of single-segment lumbar pyogenic spondylodiscitis: a retrospective cohort study

Background

A retrospective study compared the results of a lamina with spinous process (LSP) and an iliac graft (IG) as bone grafts in single-segment lumbar pyogenic spondylodiscitis (LPS) through one-stage-posterior-only approach with radical debridement and instrumentation.

Methods

A LSP was placed in 17 patients (group A), and an IG was implemented in 20 patients (group B). The surgery time, surgery hemorrhage, hospital stay, drainage, and follow-up (FU) were recorded and compared. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, visual analogue scale (VAS), Oswestry Disability Index (ODI), segmental angle, intervertebral height and bony fusion time were compared preoperatively and at the final FU.

Results

All patients were followed-up for a mean of 27.94 ± 2.35 months in group A and 30.29 ± 1.89 months in group B, without a difference. The mean age was younger in group A than in group B (P < 0.05). The surgery time, surgery hemorrhage, and hospitalization cost were lower in group A than in group B (P < 0.05), except for the hospital stay and drainage time. 10 patients in group A had fever and 12 patients in group B. The ESR, CRP level, VAS and ODI scores were significantly decreased, and no significant differences were found between the groups at the final FU. The distribution of bacterial agents in blood culture was 1 case of Aerobacter cloacae, 2 of Staphylococcus aureus, 2 of Escherichia coli, and 1 of Streptococcus viridis in group A and 1 of S. aureus, 1 of Staphylococcus warneri and 2 of Klebsiella pneumoniae in group B. Pyogenic infection was observed in the pathological findings of all patients. No significant difference was found in the mean segmental angle or mean intervertebral height preoperation and at the final FU.

Conclusion

The use of LSP could be an effective bone grafting for surgical management for the LPS while surgery is proposed as a good management strategy for single-segment LPS in carefully selected patients.

Evaluation of the effectiveness of expandable cages for reconstruction of the anterior column of the spine

PURPOSE

For anterior spine column reconstruction after corpectomy, expandable cages offer solid anterior support and allow correction of deformity, providing excellent primary stability. To provide a larger body of clinical observations concerning the effectiveness of the approach, this retrospective study examines patients treated by corpectomy and reconstruction with an expandable cage for different pathologies.

METHODS

Across 5 years, 39 patients underwent vertebral reconstruction with expandable cages after single (n = 34), double (n = 4), or triple (n = 1) corpectomy. Pathologies were tumors (n = 21), fractures, or deformities in traumatic injuries (n = 14), degenerative pathology (n = 2), and infection (n = 2). Levels were cervical (n = 10), thoracic (n = 14), and lumbar (n = 15). All patients were evaluated clinically and radiographically.

RESULTS

There were no cases of neurologic deterioration. Nurick grade showed significant improvement at 3 months postoperative versus preoperative (p < 0.01). Visual analog scale significantly improved preoperatively versus 3 and 12 months postoperatively (both p = 0). Regional angulation was significantly corrected, from preoperative to 3 and 12 months postoperative, at cervical, thoracic, and lumbar levels. We achieved reconstruction of the normal local anatomy with full recovery of the height of the vertebral body. Six patients (15.4%) had complications and two (5.1%) underwent revision surgery.

CONCLUSIONS

In our experience, expandable cages confer stable anterior support, providing significant improvement of the segmental kyphosis angle and restoration of the original somatic height. Our clinical results are favorable, and the low rate of complications and revision accentuates the expandable cage as a valuable tool to replace the vertebral body in diverse pathologies and different spine levels.

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

Objective

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

Methods

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

Results

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

Conclusion

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

A Novel Height-Adjustable Nano-Hydroxyapatite/Polyamide-66 Vertebral Body for Reconstruction of Thoracolumbar Structural Stability After Spinal Tumor Resection

BACKGROUND

Reconstruction of thoracolumbar structural stability is a formidable challenge for spine surgeons after vertebral body tumor resection. Various disadvantages of the currently used expandable or nonexpandable cages have limited their clinical applications. We sought to develop a novel prosthesis for clinical use and assess its preliminary clinical outcome in reconstruction of thoracolumbar structural stability after spinal tumor resection.

METHODS

Using data obtained from a retrospective analysis of the morphological characteristics of the thoracolumbar vertebrae and endplates in previously reported studies, we modified the nano-hydroxyapatite/polyamide-66 (n-HA/PA66) strut into a novel height-adjustable vertebral body. A retrospective study was performed of 7 patients who had undergone reconstruction of thoracolumbar structural stability with this novel prosthesis from August 2016 to January 2017.

RESULTS

A novel height-adjustable vertebral body (AHVB) composed of n-HA/PA66 with 2 separate components with a 163° contact surface at each end was manufactured. The height-adjustable range was 28-37 mm. No significant implant-related complications were observed in the process of operation. All patients experienced a significant reduction in pain, with the visual analog scale score decreasing from 7.9 to 4.0. Neurological improvement was assessed using the Frankel grading system after surgery. Postoperative radiographic and computed tomography/magnetic resonance imaging findings indicated that the operated segment was stable, the outcome of kyphosis correction was good, and no prosthesis subsidence or dislocation was observed.

CONCLUSION

This novel prosthesis has many advantages in the reconstruction of height, lordosis, and alignment after thoracolumbar spinal tumor resection and has a favorable prospect for clinical application.