Posterior interbody grafting and instrumentation for spondylodiscitis

Clinical evaluation of S1 alar screws application in short-segment lumbosacral fixation and fusion for spine infection with severe S1 vertebral body loss

Background

The one-stage posterior approach for treating spinal infection has recently been generally accepted. However, severe vertebral body loss caused by infection remains a major challenge in posterior surgery. This study was conducted to evaluate the clinical application and outcomes of S1 alar screws used in the one-stage posterior surgery of short-segment lumbosacral fixation and fusion after debridement for infection with severe S1 vertebral body loss.

Methods

The clinical features and treatment outcomes of 7 patients with spinal infections from August 2016 to August 2021 who were treated with one-stage posterior surgery using S1 alar screws were retrospectively analyzed. The clinical data, including patient data, visual analogue scale (VAS), Oswestry Disability Index (ODI), fusion time and complications of the patients, were recorded.

Results

All 7 patients were followed up for an average duration of 14.57 months (range, 12—18 months). The VAS score decreased significantly from 7.3 preoperatively (range, 6—8) to 2.6 postoperatively (range, 2—3). The ODI score demonstrated a steady and gradual increase from 73.8 preoperatively (range, 68—75) to 33.6 postoperatively (range, 30—37). Bony fusion time was observed approximately 6.8 months after surgery. Two patients in our study experienced the postoperative local pain, which could be relieved by analgesics and disappeared 3 months after the operation. There were no complications of intraoperative fracture, posterior wound infection or neurovascular injury.

Conclusions

S1 alar screws are suitable for use in the operation and could be an alternative option to S1 pedicle screws for short-segment lumbosacral fixation and fusion with severe S1 vertebral body loss caused by spinal infection, which could provide satisfactory clinical outcomes.

Management of post-operative discitis following discectomy in a tertiary-level hospital

PURPOSE

To perform retrospective analysis of 75 post-operative disc space infections after open lumbar discectomy (OLD) and to assess the outcome of their medical and surgical management in a tertiary-level hospital.

METHODS

Records of 50 men and 25 women aged 26-65 (mean, 42.53) years who underwent treatment for post-operative discitis (POD) after single level OLD at L3-4 (n = 8), L4-5 (n = 42), L5-S1 (n = 25) level. The POD was diagnosed according to specific clinical signs, laboratory and radiographic investigations and all of them received initial intravenous antibiotics (IVA) for at least 4-6 weeks followed by oral ones. Successful responders (n = 55) were considered in Group-C and remainder [Group-S (n = 20)] were operated at least after 4 weeks of failure. Demographic data, clinical variables, hospital stay, duration of antibiotic treatment and post-treatment complications were collected from the hospital record and assessment before and after treatment were done by using visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score. Comprehensive outcome was evaluated by modified criteria of Kirkaldy-Willis.

RESULTS

The mean follows up was 36.38 months. Significant improvement of mean VAS and JOA score was achieved in both conservative (76.36% satisfactory) and operative (90% satisfactory) groups although the difference was statistically insignificant.

CONCLUSION

Although insignificant, early surgical intervention provided better results (e.g. functional outcomes, length of hospital stay and duration of antibiotic treatment therapy) than conventional conservative treatment in post-operative discitis.

Conservative versus operative management of postoperative lumbar discitis

Background:

Treatment option of postoperative discitis (POD) is either conservative or operative, but till date, there are no established validated protocols of the treatment of postoperative lumbar discitis.

Aim:

The aim of this study was to assess the outcome of conservative versus operative management of POD following single-level lumbar discectomy.

Methods:

We prospectively studied a total of 38 cases of POD. The patients were diagnosed clinically, radiologically, and by laboratory investigations and followed up with serial erythrocyte sedimentation rate (ESR), C-reactive protein, X-ray, computed tomography (CT), and magnetic resonance imaging. Demographic data, clinical variables, length of hospital stay, duration of antibiotic treatment, and posttreatment complications were collected, and pre- and postoperative assessment was done using the Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) score. Functional outcome of the study was measured by the modified criteria of Kirkaldy–Willis.

Results:

VAS score for pain was significantly decreased in both groups after treatment. However, posttreatment differences were not statistically significant. In posttreatment mean JOA score, differences were not statistically significant in both groups except the mean difference (−0.47) of restriction of daily activities, which was statistically significant (95% confidence interval: −0.88–−0.07, P = 0.025, unpaired t-test). About 73.7% and 84.2% of the patients had a satisfactory functional outcome in conservative and operative management groups, respectively, at the end of 12-month follow-up.

Conclusions:

Operative management yielded better outcomes than traditional conservative treatment in terms of functional outcomes, length of hospital stays, and duration of antibiotic treatment as determined by both the pain and daily activity levels.

Minimally Invasive Surgery Combining Cortical Bone Trajectory Screws and Pedicle Screws to Treat Spondylodiskitis: Technical Notes and Preliminary Results

OBJECTIVE

Various surgical techniques for treating spondylodiskitis have been proposed, but the most appropriate surgical treatment remains controversial. In this study, we propose a new hybrid approach combining the use of cortical bone trajectory screws and pedicle screws with the technique of transforaminal lumbar interbody debridement and fusion. With this method, we can shorten the length of the segment that needs to be fixed, minimize the extent of surgical dissection, and reduce the risk of adjacent level degeneration.

METHODS

Patients with clinical and radiographic evidences of single-level lumbar spondylodiskitis seen between January and December of 2017 were included in the study. Demographic data, including age and sex, were recorded. The intraoperative details, results of culture, functional outcome, radiologic outcome, and length of hospital stay were recorded.

RESULTS

The mean age of 15 patients was 62.8 years. The mean operative time was 135 minutes, and the mean blood loss was 260 mL. The culture rate was 80%. The mean Numeric Rating Scale score and Oswestry Disability Index score significantly improved from 6.60 to 2.47 and from 21.20 to 10.20, respectively. No major perioperative complications occurred.

CONCLUSIONS

With the proposed hybrid approach using cortical bone trajectory and pedicle screws with the transforaminal lumbar interbody debridement and fusion technique, the damaged anterior column can be debrided and reconstructed, and spinal stabilization can also be achieved.

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.

Outcome of Transforminal Lumbar Thorough Debridement, Decompression, and Spondylodesis Technique in Treatment of 25 Patients with Pyogenic Spondylodiscitis

BACKGROUND

Lumbar pyogenic spondylodiscitis (LPS) is still a tangled problem in its management, especially with increasing rates of cases who underwent different spinal procedures and in patients with chronic medical disease. One-stage posterior direct transforminal lumbar thorough debridement of septic lesion, decompression, and spondylodesis (TLTDDS) are the main goals in treatment of complicated LPS without additional morbidity of anterior surgery. This is a retrospective assessment of the clinical, laboratory, functional, and radiologic outcomes in 25 patients with LPS who underwent the TLTDDS procedure.

METHODS

Twenty-nine patients with complicated LPS were treated surgically by TLTDDS surgery from January 2014 to August 2017. Complete records of 25 patients were available for evaluation. All patients were examined clinically for back or leg pain using a visual analog scale (VAS) and neurological assessment by the American Spine Injury Association. Perioperative outcome and complications were documented. All patients were serially followed up between 12 and 32 months as regard pain (VAS), functional status by Kirkaldy Willis criteria, and Oswestry disability index, laboratory, and radiologic outcomes (angle of segmental kyphosis, lumbar lordosis correction, and fusion criteria).

RESULTS

Definitive solid bony fusion was seen between 6 and 14 months, except in 3 cases, which showed probable fusion. There was significant improvement in VAS, American Spine Injury Association index, laboratory investigations, and Oswestry disability index. One patient (5%) had transient neurological deficit, which resolved completely within 2 months.

CONCLUSIONS

TLTDDS surgery is an effective procedure in the treatment of symptomatic LPS and allows abscess evacuation with adequate neural decompression, segmental kyphosis correction, and functional improvement.

One-stage posterior debridement and fusion combined with irrigation and drainage for the treatment of postoperative lumbar spondylodiscitis

Objective

The aim of this study was to evaluate the clinical outcomes of one-stage posterior debridement, interbody fusion, and instrumentation, combined with irrigation and drainage, for treating lumbar spondylodiscitis.

Methods

The study included 23 patients (13 male and 10 female, mean age: 45 years) who had posterior debridement, interbody fusion, and instrumentation, followed by continuous closed irrigation and drainage for lumbar postoperative spondylodiscitis. The visual analog scale, Oswestry disability index, and lumbar lordosis angle were assessed before and after surgery to evaluate the clinical outcome.

Results

The mean follow-up time was 27 (24–36) months. All patients tolerated the procedure well, and there were no instances of spondylodiscitis recurrence, though a dorsal dermal sinus developed in one patient after surgery. Infection was eliminated, as evidenced by the normalization of the erythrocyte sedimentation rates and C-reactive protein levels. The mean visual analog scale scores were significantly decreased after the operation. The mean lumbar lordosis angle before surgery was 21.61 ± 6.88° and the angle at the final follow-up was 31.61 ± 4.24°. The mean Oswestry disability index scores improved significantly both after the operation and at the follow-up visits (p < 0.05). Bone union was confirmed in all patients at a mean of 8.6 months post-operation, though this was not achieved until 2 years post-operation in one patient. All 3 patients who had neurological deficits showed great improvement at the last follow-up.

Conclusion

Surgical management using one-stage posterior debridement, interbody fusion, and instrumentation, followed by continuous closed irrigation and drainage, might be an effective treatment option for lumbar postoperative spondylodiscitis.

Level of evidence

Level IV, Therapeutic study.

Single-stage debridement and spinal fusion using PEEK cages through a posterior approach for eradication of lumbar pyogenic spondylodiscitis: a safe treatment strategy for a detrimental condition

Background

Pyogenic infections of the lumbar spine are a rare but critical pathology, yet with considerably high mortality rates. In cases indicating surgical therapy, the implantation of titanium cages or autologous bone grafts represent today's gold standard. Although non-metallic implants such as poly-ether-ether-ketone (PEEK) have proven to be advantageous in diverse degenerative conditions, their saftey and practicability in lumbar spine infection remains questionable. Moreover, the efficacy of a single-step radical debridement of the infected disc space with subsequent fusion from a strictly posterior approach continues to be an issue of debate. We therefore sought to evaluate the feasibility, clinical and radiological outcome of a single-step TLIF procedure using oblique PEEK cages in the surgical management of patients with lumbar pyogenic spondylodiscitis.

Methods

From January 2009 through December 2013, all patients meeting the indication for surgical treatment of lumbar pyogenic spondylodiscitis were included. Patients demonstrating intact cortical bone on preoperative CT received a single-step radical debridement of the infected intervertebral disc space, posterior screw-and-rod instrumentation and implantation of an oblique PEEK cage using the TLIF technique. Oral antibiotics were continued for 12 weeks postoperatively and clinical and radiological results recorded throughout a minimum 1-year clinical follow-up.

Results

A total of 104 patients were admitted to receive surgical therapy for lumbar pyogenic spondylodiscitis. Within this patient population, 18 patients met the diagnostic criteria to receive the implantation of an oblique PEEK cage. Pathogens were detected in 13 cases with Staph. aureus being the predominant causative organism. All patients were discharged to recover in their domestic environment. Throughout the first year of clinical and radiological follow-up and beyond, none of the 18 patients demonstrated any signs of residual neurologic deficits or recurrent infection. Furthermore, two-plane conventional X-rays showed no significant implant subsidence or failure at any of the given time-points in up to 5 years postoperatively.

Conclusions

In patients meeting the criteria for surgical treatment of lumbar pyogenic spondylodiscitis, the implantation of PEEK cages using a single-step TLIF approach is a safe and feasible procedure. Based on our experience, the concern of a recurrent infection when implanting non-metallic cages may be refuted in carefully selected patients.

Transforaminal lumbar interbody debridement and fusion for the treatment of infective spondylodiscitis in the lumbar spine

PURPOSE

To determine the safety and efficacy of using a single posterior approach with transforaminal lumbar interbody debridement and fusion (TLIDF) plus pedicle screws fixation in treating infective spondylodiscitis in the lumbar spine.

METHODS

Between January 2009 and June 2011, 28 patients with infective spondylodiscitis who underwent TLIDF, using autogenous graft and posterior pedicle screws instrumentation, met the indications for surgery, and completed more than 18 months of follow-up, were included. Clinical outcomes were assessed using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and Kirkaldy-Willis functional outcome criteria. Infection status was evaluated using C-reactive protein levels, erythrocyte sedimentation rate, and clinical symptoms. The interbody fusion status and sagittal alignment of the infected segments were assessed using radiographic studies.

RESULTS

Intra-operative culture rate was 82.1 %. The most common pathogen was methicillin-resistant Staphylococcus aureus. One post-operative deep wound infection with septic implant loosening and one instance of early aseptic implant loosening were noted. Implants in both patients were subsequently removed. Two infections recurred within 3 months post-operatively, with both subsiding within 3 months after extended antibiotic treatment. VAS and ODI values were significantly improved. The interbody fusion rate was 82.1 % and the lordotic angle of the infected segments and the lumbar spine were corrected by 9.7° and 14.3°, respectively at the last follow-up.

CONCLUSIONS

A single posterior approach with TLIDF and pedicle screws instrumentation for lumbar infective spondylodiscitis provided a satisfactory clinical outcome, adequate infection control and good fusion rate, and this strategy avoids the risks of anterior or staging surgeries.