Surgical outcomes of infectious spondylitis after vertebroplasty, and comparisons between pyogenic and tuberculosis

Spinal infection after vertebral augmentation: a covert complication with serious havoc

INTRODUCTION

Vertebral augmentation, including percutaneous vertebroplasty (PVP) or kyphoplasty (PKP), is the current least invasive surgical option and has been widely used to treat the painful osteoporotic vertebral compression fractures (OVCF). However, the postoperative infections could be life-threatening, even though they rarely occur. Our studies aim to clarify the causation and outcomes of spinal infections following augmentation and meanwhile to identify the risk factors.

METHODS

A retrospective study was conducted on patients with OVCF who underwent PVP or PKP, and were subsequently admitted to our institution with postoperative spinal infection between January 2010 and December 2022. A total of 33 patients were finally included.

RESULTS

The rate of spinal infection after augmentation in our single institute was 0.05% (2/3893). In addition to these 2 patients, the remaining 31 were referred from other hospitals. All 33 patients exhibited elevated inflammatory parameters, 14 patients presented with fever, and 9 patients experienced neurological deficits. Additionally, 29 patients had comorbidity and risk factors. Pathogens were identified in 26 patients, while only 7 patients were examined as culture negative. 27 patients underwent revision surgery and 6 patients only received conservative therapy. Anterior surgery was performed in 2 patients, while posterior surgery was performed in 20 patients. A combined anterior-posterior surgery was performed in 5 patients. At the final follow-up, 18 patients had unrestricted mobility, 10 patients required assistance from crutches or a walker for ambulation, 4 patients needed a wheelchair, and 1 patients died after revision surgery.

CONCLUSIONS

Spinal infection after vertebral augmentation is rare, but it cannot be ignored. Surgeons should make every effort to detect the potential preoperative spondylitis or discitis. Once postoperative spinal infection is confirmed, a prompt intravenous antibiotic therapy is warranted. If medication therapy fails, revision surgery involving debridement and spinal reconstruction should be considered.

A rare case of aggressive pyogenic spondylitis with giant abscesses after vertebral augmentation

Although Streptococcus constellatus (SC), an opportunistic pathogen, can cause abscesses and empyema. The SC infection after vertebral augmentation (VA) can interfere with patients' daily living activities and can be life-threatening in severe cases. A 67-year-old male complained of lumbar pain for two months. The patient underwent percutaneous vertebroplasty of the second and third lumbar vertebrae two months ago. On admission, laboratory and imaging evidence suggested infection of the second and third lumbar vertebrae with bilateral psoas major and left lumbodorsal abscesses. After three weeks of empirical anti-infective therapy, abscess removal and the second and third lumbar vertebrae fusion with iliac bone graft were performed under general anesthesia. Intraoperative pathology and next-generation sequencing (NGS) examination of the pus suggested SC infection, and oral linezolid was given for 12 weeks after surgery. The infection was eventually cured and the patient achieved satisfactory function. In conclusion, pyogenic spondylitis due to SC infection after VA is a life-threatening complication. In addition to infectious disease consultation and routine etiological screening, NGS is important to identify infection with unknown pathogens. Surgery combined with sensitive antibiotics is appropriate for patients with progressive neurological deficits.

Current status and challenges of percutaneous vertebroplasty (PVP)

A narrative review regarding percutaneous vertebroplasty (PVP) for osteoporotic vertebral fracture (OVF) is provided herein, addressing the epidemic of OVF in Japan, the latest response to the criticism of PVP for OVFs, the indications and potential risks of PVP for OVFs, and a future perspective for PVP. Each year in Japan, approximately 32,000 patients aged 55 years or older suffer from chronic low back pain for several months to several years due to a compression fracture. PVP is one of the surgical treatments for an OVF, and it is less invasive compared to the traditional open surgery. PVP is suitable for OVF patients who have difficulty walking as assessed by the modified Yokoyama's activities of daily living (ADL) scoring system, and for patients with Kummell's disease diagnosed by CT and MRI examinations. Serious adverse events related to PVP occur in 1.1-3.3% of the cases, but direct deaths from PVP are extremely rare at less than 1%. Recent studies demonstrated that OVF patients treated with PVP are less likely to die after the treatment than non-surgically treated patients, which conflicts with the Cochran reviews' conclusion not supporting PVP for OVFs. Novel robotic systems and procedure-support devices are being developed, providing a next step toward fully automated PVP procedures.

Risk factors for tuberculous or nontuberculous spondylitis after percutaneous vertebroplasty or kyphoplasty in patients with osteoporotic vertebral compression fracture: A case-control study

Objectives

The contributing factors for spondylitis after percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) remain unclear. Here, we sought to investigate the factors affecting spondylitis occurrence after PVP/PKP. We also compared the clinical characteristics between patients with tuberculous spondylitis (TS) and nontuberculous spondylitis (NTS) following vertebral augmentation.

Methods

Literature searches (from January 1, 1982 to October 16, 2020) using MEDLINE, EMBASE, Google Scholar and Web of science databases were conducted to identify eligible studies according to predefined criteria. The local database was also retrospectively reviewed to include additional TS and NTS patients at our center.

Results

Thirty studies from the literature and 11 patients from our local institute were identified, yielding a total of 23 TS patients and 50 NTS patients for analysis. Compared with NTS group, patients in the TS group were more likely to have a history of trauma before PVP/PKP treatment. Univariate analyses of risk factors revealed pulmonary tuberculosis and diabetes were significant factors for TS after PVP/PKP. Analyzing NTS, we found obesity, a history of preoperative trauma, urinary tract infection, diabetes and multiple surgical segments (≥2) were significantly associated with its occurrence following PVP/PKP treatment. Multivariate logistic analyses showed a history of pulmonary tuberculosis and diabetes were independent risk factors for TS after PVP/PKP, while diabetes and the number of surgically treated segments independently influenced NTS development.

Conclusions

A history of pulmonary tuberculosis and diabetes were independent risk factors for TS. For NTS, diabetes and the number of surgically treated segments significantly influenced the occurrence of postoperative spinal infection. These data may be helpful for guiding risk stratification and preoperative prevention for patients, thereby reducing the incidence of vertebral osteomyelitis after PVP/PKP.

Multidisciplinary Care of a Vertebral Fracture in a Patient with Hematopoietic Stem Cell Transplant: Safety Appropriateness in Interventional Pain Management and Rehabilitation Considerations

Bone loss leading to fragility fracture is a highly prevalent late effect in hematopoietic stem-cell transplant patients, who are affected 8–9 times more than the general population, particularly for vertebral compression fractures. Spinal interventions such as lumbar epidural steroid injections and vertebral augmentation may be helpful for providing pain relief and improved function, quality of life and return to ambulation. However, interventional procedures should be approached with caution in these patients. Our study found that there is a paucity of scientific studies addressing the risks of spinal injections in these patients and there is no absolute recommendation specific to spinal injections in patients receiving immunosuppressive agents or who have a history of solid organ or hematopoietic stem cell transplant. It is imperative to consider proper timing of the intervention to minimize risks while optimizing the benefits of the intervention combined with a well-defined post-transplant rehabilitation plan. Moreover, the decision to proceed with spinal interventions should be done case by case and with caution. Therefore, this article reports the case of a multidisciplinary treatment for a vertebral compression fracture in a patient with a hematopoietic stem-cell transplant, in particular discussing safety appropriateness in interventional pain management and rehabilitation considerations for this condition in this patient population.

Revision surgery after cement augmentation for osteoporotic vertebral fracture

INTRODUCTION

Cement augmentation has been proven to be a safe procedure for the treatment of osteoporotic vertebral fracture, and the overall result is encouraging. However, failures caused by different complications are not uncommon, and a few patients even need revision surgery. This retrospective study aimed to investigate the primary causes of revision surgery after cement augmentation for osteoporotic vertebral fracture and how to prevent them, and the second objective was to evaluate the clinical results of revision surgery.

HYPOTHESIS

The main hypothesis is that infection and neurological dysfunction are the prime causes of revision surgery after cement augmentation for osteoporotic vertebral fracture, and the second hypothesis is that revision surgery is effective to improve the quality of daily life.

MATERIALS AND METHODS

Twenty-one patients who underwent unplanned revision surgery after cement augmentation were retrospectively analyzed. The initial radiographic and medical records were reviewed to re-evaluate whether the initial diagnosis and surgical procedure were correct and suitable. The primary causes of revision surgery and the details were recorded. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were used to evaluate the efficacy of the revision surgery, and patients with neurological dysfunction were evaluated with the American Spinal Injury Association (ASIA).

RESULTS

A total of 47.6% (10/21) of patients were misdiagnosed initially or had an incorrect indication for cement augmentation surgery, including 3 pre-existing spondylitis cases that were misdiagnosed as osteoporotic vertebral fracture and 7 cases of three column fractures that were treated with cement augmentation. The primary causes and details of the revision surgeries were as follows: 7 patients with infection underwent anterior and/or posterior debridement and fixation; 9 patients with progressive kyphosis underwent posterior osteotomy and fixation; and 5 patients with neurological dysfunction underwent posterior decompression and fixation. The mean follow-up time was 30.6±8.7 months, the VAS score decreased from 7.3±1.1 preoperatively to 2.3±0.3 (p<0.05) at the last follow-up, the ODI decreased from 61.1%±16.3% preoperatively to 20.6%±6.2% (p<0.05) at the last follow-up, and 5 patients with neurological dysfunction improved by at least one grade.

CONCLUSION

Infection, progressive kyphosis and neurological dysfunction are the primary causes of revision surgery after cement augmentation for osteoporotic vertebral fracture. Avoiding misdiagnosis and ensuring suitable indications might be the key points to decreasing unplanned revision surgery for cement augmentation for osteoporotic vertebral fracture. The quality of daily life and neurological function can be improved through revision surgery.

Simultaneous-onset infectious spondylitis with vertebral fracture mimicking an acute osteoporotic vertebral fracture erroneously treated with balloon kyphoplasty: illustrative case

BACKGROUND

Early balloon kyphoplasty (BKP) intervention for acute osteoporotic vertebral fracture (OVF) has been reported to be more effective than the conservative treatment. However, complications of early BKP intervention are still unknown.

OBSERVATIONS

A 71-year-old patient with OVF of L2 underwent BKP 2 weeks after symptom onset. Preoperative magnetic resonance imaging (MRI) and radiograph were compatible with new L2 OVF. Although computed tomography (CT) images revealed the atypical destruction of lower endplate of L2 as OVF, L2 BKP was planned. After BKP, his back pain improved dramatically. Two weeks after BKP, his lower back pain recurred. MRI and CT confirmed the diagnosis of infectious spondylitis with paravertebral abscess formation. With adequate antibiotic treatment and rehabilitation, he was symptom-free and completely ambulatory without signs of infection.

LESSONS

Signal changes on the fractured vertebral bodies during initial MRI and fractured vertebral instability on radiograph can mislead the surgeon to interpret the infection as a benign compression fracture. If the patients exhibit unusual destruction of the endplate on CT imaging, “simultaneous-onset” spondylitis with vertebral fracture should be included in the differential diagnosis. To determine the strategy for OVF, preoperative biopsy is recommended if simultaneous-onset spondylitis with vertebral fracture is suspected.

Debridement and corpectomy via single posterior approach to treat pyogenic spondylitis after vertebral augmentation

Background

Infection after vertebral augmentation (VA) often limits the daily activities of patients and even threatens their life. The operation may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability. This study aimed to investigate the clinical efficacy of the treatment of pyogenic spondylitis after vertebral augmentation (PSVA) with Single posterior debridement, vertebral body resection, and intervertebral bone graft fusion and internal fixation (sPVRIF).

Methods

The study was performed on 19 patients with PSVA who underwent VA at 4 hospitals in the region between January 2010 and July 2020. Nineteen patients were included. Among them, 16 patients underwent sPVRIF to treat the PSVA.

Results

A total of 2267 patients underwent VA at 4 hospitals in the region. Of the 19 patients with postoperative PSVA, suppurative spondylitis was misdiagnosed as an osteoporotic vertebral fracture(OVF) in 4 patients and they underwent VA. Besides osteoporosis, 18 patients had other comorbidities. The average interval between the first surgery and the diagnosis of PSVA was 96.4 days. Of the 19 patients, 16 received surgical treatment. The surgical time was 175.0±16.8 min, and the intraoperative blood loss was 465.6±166.0 mL. Pathogenic microorganisms were cultured in 12 patients.

Conclusion

PSVA is a severe complication that can even threaten the life of the patients. sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability.

Cement Plug Fragmentation Following Percutaneous Cementoplasty of the Bony Pelvis: Is it a Frequent Finding in Clinical Practice?

PURPOSE

To report the rate of fragmentation of the cement plug following percutaneous cementoplasty with polymethylmethacrylate (PMMA) in the bony pelvis (i.e., pelvic bones or sacrum).

MATERIALS AND METHODS

Post-interventional and follow-up CT scans of 56 patients (36 men; mean age of 68.4 ± 15.4) with a total of 98 percutaneous cementoplasty procedures were analyzed. Indications for treatment included painful malignant tumors (42.9%; 42/98) and insufficiency fractures (57,1%; 56/98). Fragmentation of PMMA was recorded for each cement plug.

RESULTS

Mean interval between the procedure and the last available CT scan was 29.3 ± 18.8 months. There was no significant difference between the length of follow-up of malignant lesions (27.6 ± 15.1 months) and insufficiency fractures (29 ± 20.5 months) (p = 0.69). Fragmentation was diagnosed following 2/98 (2%) procedures, both in the malignant lesions group. The time intervals between the procedure and the first visualization of cement fragmentation were 6 for the first and 24 months for the second patient.

CONCLUSION

Fragmentation of the PMMA plug following percutaneous cementoplasty in the bony pelvis is a rare finding at midterm follow-up. It was only observed in cementoplasty performed in malignant lesions and seems to be more a consequence of local mechanical stresses than as a result of porosity.

An unusual Staphylococcus saccharolyticus spondylodiscitis post kyphoplasty: a case report

Background

Staphylococcus saccharolyticus is a rarely encountered coagulase-negative, which grows slowly and its strictly anaerobic staphylococcus from the skin. It is usually considered a contaminant, but some rare reports have described deep-seated infections. Virulence factors remain poorly known, although, genomic analysis highlights pathogenic potential.

Case presentation

We report a case of Staphylococcus saccharolyticus spondylodiscitis that followed kyphoplasty, a procedure associated with a low rate but possible severe infectious complication (0.46%), and have reviewed the literature. This case specifically stresses the risk of healthcare-associated S. saccharolyticus infection in high-risk patients (those with a history of alcoholism and heavy smoking).

Conclusion

S. saccharolyticus infection is difficult to diagnose due to microbiological characteristics of this bacterium; it requires timely treatment, and improved infection control procedure should be encouraged for high-risk patients.

Percutaneous Vertebral Body Augmentations: The State of Art

Osteoporotic compression fractures of the vertebral body can result in pain and long-term morbidity, including spinal deformity, with increased risk of mortality resulting from associated complications. Conservative management includes opioids and other analgesics, bed rest, and a back brace. For patients with severe and disabling pain, vertebral augmentation (vertebroplasty and kyphoplasty) is often considered, with these procedures endorsed by multiple professional societies, and provides immediate structural support, and stabilizes and reinforces the weakened bone structure. The purpose of this article is to review the vertebral biomechanics, indications and contraindications, and techniques of performing successful vertebral augmentation.

Vertebral collapse and polymethylmethacrylate breakage after vertebroplasty: A case report

RATIONALE

Vertebral augmentation has become the main treatment for osteoporotic vertebral fractures (VFs). In this article, we report a very rare case of vertebral collapse and polymethylmethacrylate (PMMA) breakage after vertebroplasty. We describe the clinical characteristics and revision surgery performed to remove the broken PMMA cement, maintain stability, and corrects the kyphotic deformity, and we analyze the possible causes.

PATIENT CONCERNS

A 72-year-old man who suffered back pain underwent first lumbar vertebra (L1) percutaneous vertebroplasty (PVP) due to osteoporosis and a vertebral fracture in May 2013. Postoperatively, the patient's back pain was markedly alleviated. Unfortunately, his lumbar back pain recurred in November 2015.

DIAGNOSES

Plain radiographs showed collapse of the L1 vertebral body, breakage of the PMMA cement, and severe kyphosis at the thoracolumbar junction.

INTERVENTIONS

The posterior pedicle was internally fixed and an anterior artificial vertebral body implant was placed to maintain stability and correct the kyphotic deformity in a 2-step surgical procedure.

OUTCOMES

The back pain was alleviated and the patient returned to daily life for more than two years.

LESSONS

This case demonstrates that PVP is not a simple minimally invasive surgery, and significant postsurgical care is necessary. The true cause of this rare phenomenon remains unclear, but the long-term use of steroids, new injuries, and poorly corrected kyphosis after PVP may play a role. Surgeons must be aware of the kinds of complications that may occur, including rare complications such as vertebral lysis.