Use of structural allografts in spinal osteomyelitis: a review of 47 cases

Management of Refractory Post-operative Osteomyelitis and Discitis: A Case Report

Vertebral osteomyelitis/discitis is a relatively rare disease but is a known potential complication of spinal surgical intervention. In general, the first-line treatment for this condition is targeted antibiotic therapy with surgical intervention only utilized in refractory cases with evidence of extensive damage, structural instability, or abscess formation. However, surgical best practices have not been established for osteomyelitis, including indications for anterior lateral interbody fusion (ALIF), posterior lateral interbody fusion (PLIF), or direct lateral interbody fusion (DLIF). This case provides a discussion of the indications that led to a direct lateral approach in the setting of refractory osteomyelitis/discitis, supporting factors that led to its success, and the efficacy of utilizing intraoperative neuromonitoring in cases of infection.

Impact of Gamma Irradiation on the Properties of Magnesium-Doped Hydroxyapatite in Chitosan Matrix

This is the first report regarding the effect of gamma irradiation on chitosan-coated magnesium-doped hydroxyapatite (x_Mg = 0.1; 10 MgHApCh) layers prepared by the spin-coating process. The stability of the resulting 10 MgHApCh gel suspension used to obtain the layers has been shown by ultrasound measurements. The presence of magnesium and the effect of the irradiation process on the studied samples were shown by X-ray photoelectron spectroscopy (XPS). The XPS results obtained for irradiated 10 MgHApCh layers suggested that the magnesium and calcium contained in the surface layer are from tricalcium phosphate (TCP; Ca₃(PO₄)₂) and hydroxyapatite (HAp). The XPS analysis has also highlighted that the amount of TCP in the surface layer increased with the irradiation dose. The energy-dispersive X-ray spectroscopy (EDX) evaluation showed that the calcium decreases with the increase in the irradiation dose. In addition, a decrease in crystallinity and crystallite size was highlighted after irradiation. By atomic force microscopy (AFM) we have obtained images suggesting a good homogeneity of the surface of the non-irradiated and irradiated layers. The AFM results were also sustained by the scanning electron microscopy (SEM) images obtained for the studied samples. The effect of gamma-ray doses on the Fourier transform infrared spectroscopy (ATR-FTIR) spectra of 10 MgHApCh composite layers was also evaluated. The in vitro antifungal assays proved that 10 MgHApCh composite layers presented a strong antifungal effect, correlated with the irradiation dose and incubation time. The study of the stability of the 10 MgHApCh gel allowed us to achieve uniform and homogeneous layers that could be used in different biomedical applications.

Severity and Outcome of Neurologic Deficits in Patients with Pyogenic Spondylodiscitis: A Systematic Review

Patients with advanced pyogenic spondylodiscitis can present with neurologic deficits. However, the prevalence, severity, and outcome of the neurologic deficits are not well known. A systematic review was performed to improve the knowledge of this commonly encountered clinical scenario. The considerable number of severe neurologic deficits in addition to their poor recovery, even after surgical intervention, demonstrates that the early diagnosis of pyogenic spondylodiscitis is crucial. Prompt surgical intervention is likely associated with a greater chance of improvement of neurologic status than nonsurgical treatment.

Risks of Using Sterilization by Gamma Radiation: The Other Side of the Coin

The standard sterilization method for most medical devices over the past 40 years involves gamma irradiation. During sterilization, gamma rays efficiently eliminate microorganisms from the medical devices and tissue allografts, but also significantly change molecular structure of irradiated products, particularly fragile biologics such as cytokines, chemokines and growth factors. Accordingly, gamma radiation significantly alters biomechanical properties of bone, tendon, tracheal, skin, amnion tissue grafts and micronized amniotic membrane injectable products. Similarly, when polymer medical devices are sterilized by gamma radiation, their physico-chemical characteristics undergo modification significantly affecting their clinical use. Several animal studies demonstrated that consummation of irradiated food provoked genome instability raising serious concerns regarding oncogenic potential of irradiated consumables. These findings strongly suggest that new, long-term, prospective clinical studies should be conducted in near future to investigate whether irradiated food is safe for human consumption. In this review, we summarized current knowledge regarding molecular mechanisms responsible for deleterious effects of gamma radiation with focusing on its significance for food safety and biomechanical characteristics of medical devices, and tissue allografts, especially injectable biologics.

Pyogenic Vertebral Osteomyelitis: Clinical Features, Diagnosis, and Treatment

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

Bone substitutes and expanders in Spine Surgery: A review of their fusion efficacies

STUDY DESIGN

A narrative review of literature.

OBJECTIVE

This manuscript intends to provide a review of clinically relevant bone substitutes and bone expanders for spinal surgery in terms of efficacy and associated clinical outcomes, as reported in contemporary spine literature.

SUMMARY OF BACKGROUND DATA

Ever since the introduction of allograft as a substitute for autologous bone in spinal surgery, a sea of literature has surfaced, evaluating both established and newly emerging fusion alternatives. An understanding of the available fusion options and an organized evidence-based approach to their use in spine surgery is essential for achieving optimal results.

METHODS

A Medline search of English language literature published through March 2016 discussing bone graft substitutes and fusion extenders was performed. All clinical studies reporting radiological and/or patient outcomes following the use of bone substitutes were reviewed under the broad categories of Allografts, Demineralized Bone Matrices (DBM), Ceramics, Bone Morphogenic proteins (BMPs), Autologous growth factors (AGFs), Stem cell products and Synthetic Peptides. These were further grouped depending on their application in lumbar and cervical spine surgeries, deformity correction or other miscellaneous procedures viz. trauma, infection or tumors; wherever data was forthcoming. Studies in animal populations and experimental in vitro studies were excluded. Primary endpoints were radiological fusion rates and successful clinical outcomes.

RESULTS

A total of 181 clinical studies were found suitable to be included in the review. More than a third of the published articles (62 studies, 34.25%) focused on BMP. Ceramics (40 studies) and Allografts (39 studies) were the other two highly published groups of bone substitutes. Highest radiographic fusion rates were observed with BMPs, followed by allograft and DBM. There were no significant differences in the reported clinical outcomes across all classes of bone substitutes.

CONCLUSIONS

There is a clear publication bias in the literature, mostly favoring BMP. Based on the available data, BMP is however associated with the highest radiographic fusion rate. Allograft is also very well corroborated in the literature. The use of DBM as a bone expander to augment autograft is supported, especially in the lumbar spine. Ceramics are also utilized as bone graft extenders and results are generally supportive, although limited. The use of autologous growth factors is not substantiated at this time. Cell matrix or stem cell-based products and the synthetic peptides have inadequate data. More comparative studies are needed to evaluate the efficacy of bone graft substitutes overall.

Mesh cage for treatment of hematogenous spondylitis and spondylodiskitis. How safe and successful is its use in acute and chronic complicated cases? A systematic review of literature over a decade

BACKGROUND

Surgical treatment of hematogenous pyogenic spondylitis and spondylodiskitis includes anterior debridement, stabilization, and fusion. Titanium mesh cage (TMC) has been advocated to immediately correct deformity and eradicate infection with low recurrence rates. There are no comprehensive reviews on TMC.

PURPOSE

To evaluate recorded information regarding surgical outcome with the use of TMC for treating patients with pyogenic spinal infection.

STUDY DESIGN

Comprehensive review.

METHODS

The terms "titanium cage", "spine", "infection" were searched. A total of 486 peer-reviewed papers published from 2002 to 2012 were obtained from PubMed search. Fifteen Level IV articles with 363 patients were enrolled for consideration. Finally, 192 (53 %) patients who received TMC were eligible and included in this review. Age, comorbidities, indications for surgery, abscess formation, time lapsed between symptoms initiation and surgery, microbiology, radiological spine restoration, neurological outcome, and complications following surgery are evaluated.

RESULTS

The average age at the index surgery was 57 years, range 15-85 years. The reported time lapsed from symptoms presentation to diagnosis varied significantly from 1 week to 2 years. On admission, there reported paravertebral and/or epidural abscess in 48 % and neurological impairment in 51 % of the patients. One hundred and seventy-seven comorbidities were recorded in 192 patients. Bone biopsy and culture revealed gram (+) bacteria in 71 %, gram (-) in 24 %, and multiple bacteria in 1 %, while it was negative in 3.1 % of the patients. TMC was most commonly (49 %) implanted in the lumbar spine. The follow-up observation following surgery averaged 26 months, range 10-116 months. Most of the studies reported decrease in segmental kyphosis and neurological improvement in incomplete lesions postoperatively. TMC was primarily revised for early dislodgment or cage misplacement in 3.2 % of the patients. Infection recurrence was recorded in two patients (1.3 %), but revision surgery needed in one (0.65 %) patient. Mortality was reported in 5.8 % of the patients.

CONCLUSIONS

TMC offers an advantageous and safe technique for spinal debridement and fusion for hematogenous spinal infection. TMC safeguarded medium-term spinal stability with low infection recurrence rates, which were independent form causative pathogen, age, and comorbidities.

Surgical treatment of pyogenic spondylitis with the use of freeze-dried structural allograft

OBJECTIVE

Radical debridement and reconstruction is necessary for surgical treatment of pyogenic spondylitis to control infection and to provide segmental stability. The authors identified 25 patients who underwent surgery for pyogenic spondylitis using freeze-dried structural allograft for reconstruction. This study aimed to evaluate and demonstrate the effectiveness and safety of a freeze-dried structural allograft during the surgical treatment of pyogenic spondylitis.

METHODS

From January 2011 to May 2013, we retrospectively reviewed 25 surgically treated patients of pyogenic spondylitis. Surgical techniques used were anterior radical debridement and reconstruction with a freeze-dried structural allograft and instrumentation. In these 25 patients, we retrospectively examined whether the symptoms had improved and the infection was controlled after surgery by evaluating laboratory data, clinical and radiological outcomes. The average follow-up period was 15.7 months (range, 12.2-37.5 months).

RESULTS

The infection resolved in all of the patients and there were no cases of recurrent infection. The mean Visual Analog Scale score was 6.92 (range, 5-10) before surgery and 1.90 (range, 0-5) at the time of the last follow-up. Preoperatively, lower extremity motor deficits related to spinal infection were noted in 10 patients, and they improved in 7 patients after surgery. Follow-up computed tomographic scans were obtained from 10 patients, and osseous union between the vertebral body and the structural allograft was achieved in 2 patients.

CONCLUSION

The freeze-dried structural allograft can be a safe and effective alternative for surgical treatment of pyogenic spondylitis, and another option for vertebral reconstruction instead of using the other materials.

One-stage biopsy, debridement, reconstruction, and stabilization of pyogenic vertebral osteomyelitis

Study Design Retrospective cohort study. Objective To evaluate whether the proposed one-stage biopsy, culture, debridement, and reconstruction with stabilization strategy is a viable option for pyogenic vertebral osteomyelitis (PVO). PVO is increasing in frequency globally, particularly in immunologically compromised individuals. Typically, biopsy and culture sensitivity followed by staged surgery and long-term antibiotic therapy is the mainstay of therapy. Methods This is a study of a group of 32 consecutive cases of PVO (spondylodiskitis) treated in our institution from 2010 to 2012. All cases had one-stage biopsy, culture sensitivity, debridement, reconstruction with iliac bone graft, and stabilization with titanium implants. The mean age in this series was 51 years, and the male-to-female ratio was 2.2:1. Approximately 50% of the patients had impaired immunity status. The commonest organism isolated was Pseudomonas aeruginosa. Culture-specific antibiotics were given for a minimum of 6 weeks to all patients. The follow-up period ranged from 6 months to a maximum of 2 years. All patients were assessed for wound healing, recurrence of infection, deformity progression, pain, and healing by radiologic and biochemical parameters. No generic or disease-specific outcome tools were used for this study. Results All patients had good wound healing, although there was one case of superficial infection that was resolved with debridement. There were two implant failures with pseudarthrosis and one localized kyphosis in this series. Conclusions The one-stage technique of biopsy, debridement, bone grafting, and stabilization can be recommended for most cases of PVO.

Spinal infection: state of the art and management algorithm

INTRODUCTION

Spinal infection is a rare pathology although a concerning rising incidence has been observed in recent years. This increase might reflect a progressively more susceptible population but also the availability of increased diagnostic accuracy. Yet, even with improved diagnosis tools and procedures, the delay in diagnosis remains an important issue. This review aims to highlight the importance of a methodological attitude towards accurate and prompt diagnosis using an algorithm to aid on spinal infection management.

METHODS

Appropriate literature on spinal infection was selected using databases from the US National Library of Medicine and the National Institutes of Health.

RESULTS

Literature reveals that histopathological analysis of infected tissues is a paramount for diagnosis and must be performed routinely. Antibiotic therapy is transversal to both conservative and surgical approaches and must be initiated after etiological diagnosis. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and upon failure of conservative treatment.

CONCLUSIONS

A methodological assessment could lead to diagnosis effectiveness of spinal infection. Towards this, we present a management algorithm based on literature findings.

L5 vertebral osteomyelitis treated with L5 corpectomy and anterior instrumentation: case report

Study design: A case report.

Objective: Pyogenic osteomyelitis is the most common form of vertebral infection and typically resolves following conservative treatment with antibiotics administered long term and immobilization. In cases of spinal instability, severe neurological deficit or disease refractory to medical management, neurosurgical intervention is warranted. Historically, these patients have undergone radical vertebral debridement and grafting with or without posterior instrumentation. We report the case of a 46-year-old female intravenous drug user presenting with L5 pyogenic osteomyelitis with L5 vertebral compression and cortex retropulsion following L2–L4 laminectomy for epidural abscess 8 weeks prior.

Methods: The patient underwent an anterior approach single-stage L5 corpectomy, L4/5 and L5/S1 discectomies, expandable titanium-cage insertion and anterior plating from L4 to the sacrum.

Results: The patient recovered without any complications. The infection was successfully eradicated and her fusion remains solid 18 months postoperatively.

Conclusions: To our knowledge, this is the first case of L5 vertebral osteomyelitis treated with a single-stage corpectomy and anterior instrumentation.

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

PURPOSE

Surgical treatment of thoracolumbar osteomyelitis consists of radical debridement, reconstruction of anterior column either with or without posterior stabilization. The objective of present study is to evaluate a case series of patients with osteomyelitis of thoracic and lumbar spine treated by single, posterior approach with posterior instrumentation and anterior column reconstruction.

METHODS

Seventeen patients underwent clinical and radiological evaluation pre and postoperatively with latest follow-up at 19 months (8-56 months) after surgery. Parameters assessed were site of infection, causative organism, angle of deformity, blood loss, duration of surgery, ICU stay, deformity correction, time to solid bony fusion, ambulatory status, neurologic status (ASIA impairment scale), and functional outcome (Kirkaldy-Willis criteria).

RESULTS

Mean operating time was 207 min and average blood loss 1,150 ml. Patients spent 2 (1-4) days in ICU and were able to walk unaided 1.6 (1-2) days after surgery. Infection receded in all 17 patients postoperatively. Solid bony fusion occurred in 15 out of 17 patients (88 %) on average 6.3 months after surgery. Functional outcome was assessed as excellent or good in 82 % of cases. Average deformity correction was 8 (1-18) degrees, with loss of correction of 4 (0-19) degrees at final follow-up.

CONCLUSIONS

Single, posterior approach addressing both columns poses safe alternative in treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine. It proved to be less invasive resulting in faster postoperative recovery.

Pyogenic spondylitis

Pyogenic spondylitis is a neurological and life threatening condition. It encompasses a broad range of clinical entities, including pyogenic spondylodiscitis, septic discitis, vertebral osteomyelitis, and epidural abscess. The incidence though low appears to be on the rise. The diagnosis is based on clinical, radiological, blood and tissue cultures and histopathological findings. Most of the cases can be treated non-operatively. Surgical treatment is required in 10–20% of patients. Anterior decompression, debridement and fusion are generally recommended and instrumentation is acceptable after good surgical debridement with postoperative antibiotic cover.

Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine

Anterior radical debridement and bone grafting is popular in the treatment of pyogenic infection of the spine, but there remains great concern of placing instrumentation in the presence of infection because of the potentiality of infection recurrence after surgery. The objective of this study was to prospectively evaluate the efficacy and safety of anterior instrumentation in patients who underwent simultaneous anterior debridement and autogenous bone grafting for the treatment of pyogenic vertebral osteomyelitis. The series consisted of 22 consecutive patients who were treated with anterior debridement, interbody fusion with autogenous bone grafting and anterior instrumentation for pyogenic vertebral osteomyelitis of thoracic and lumbar spine. The patients were prospectively followed up for a minimum of 3 years (average 46.1 months; range 36-74 months). Data were obtained for assessing clinically the neurological function and pain and radiologically the spinal alignment and fusion progress as well as recurrence of the infection. All the patients experienced complete or significant relief of back pain with rapid improvement of neurological function. Kyphosis was improved with an average correction rate of 93.1% (range 84-100%). Solid fusion and healing of the infection was achieved in all the patients without any evidence of recurrent or residual infection. The study shows that combined with perioperative antibiotic regimen, anterior instrumentation is effective and safe in the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine directly following radical debridement and autogenous bone grafting.

Bone morphogenetic protein-2 (BMP-2) in the treatment of pyogenic vertebral osteomyelitis

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To present results of recombinant human bone morphogenetic protein-2 (rhBMP-2) use in medically nonresponsive pyogenic vertebral osteomyelitis (PVO), treated by anterior/posterior debridement and instrumented fusion in the cervical, thoracic, and lumbosacral spine.

SUMMARY OF BACKGROUND DATA

Surgical options for PVO vary, as do their outcomes, and can be complicated by recurrence, pseudarthrosis, and death. Although rhBMP-2 use in spinal fusion is increasing, its utility in PVO is unknown. Additionally, use in areas of infection is listed as a contraindication, although this is not supported by laboratory (animal) studies or clinical studies in long bones.

METHODS

Between 2003 and 2005, 14 patients who underwent circumferential fusion for PVO were included in this study. Average patient age was 54 years (range, 27-77 years). Eight (57%) patients had 3 or more vertebral bodies involved. Diagnostic studies included radiographs, CT, MRI, and markers of infection [(C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood count (WBC)]. All patients underwent anterior fusion with rhBMP-2 inserted in structural allograft (11 patients) or titanium cylindrical cages (3 patients), followed by posterior instrumented fusion with autogenous iliac crest graft (8 occurring on the same day). Follow-up averaged 22 months (range, 11-30 months). All were studied with plain radiographs, including flexion-extension lateral films and fine cut CT scans with reconstruction. Pain ratings were recorded by visual analog scores (VAS).

RESULTS

Clinical resolution of infections, normalization of lab values, and bony fusion, based on dynamic radiographs and CT scans, were seen in all patients at latest follow-up. Staphylococcus aureus was the most frequently identified organism (8 patients). Four (29%) patients had positive blood cultures (all MRSA). Predisposing comorbidities were present in 12 patients. Six patients had epidural abscesses. Eight (57%) patients presented with neurologic deficits, ranging from paraparesis to quadriplegia. Complete recovery was seen in 7 (quadriplegia unchanged). At 1 year, mean VAS pain scores improved significantly (P < 0.05) from 7.9 (range, 3-10) to 2.8 (range, 0-6). Perioperative complications (non-BMP related) occurred in 2 patients. There were no surgically-related deaths.

CONCLUSION

rhBMP-2 use, in combination with antibiotics and circumferential instrumented fusion, provides a safe and successful surgical treatment of medically nonresponsive PVO, with solid fusions obtained, good clinical results, and no adverse side effects from the BMP.

Surgical treatment of pyogenic vertebral osteomyelitis with spinal instrumentation

Pyogenic vertebral osteomyelitis responds well to conservative treatment at early stage, but more complicated and advanced conditions, including mechanical spinal instability, epidural abscess formation, neurologic deficits, and refractoriness to antibiotic therapy, usually require surgical intervention. The subject of using metallic implants in the setting of infection remains controversial, although more and more surgeons acknowledge that instrumentation can help the body to combat the infection rather than to interfere with it. The combination of radical debridement and instrumentation has lots of merits such as, restoration and maintenance of the sagittal alignment of the spine, stabilization of the spinal column and reduction of bed rest period. This issue must be viewed in the context of the overall and detailed health conditions of the subjecting patient. We think the culprit for the recurrence of infection is not the implants itself, but is the compromised general health condition of the patients. In this review, we focus on surgical treatment of pyogenic vertebral osteomyelitis with special attention to the role of spinal instrumentation in the presence of pyogenic infection.

Delayed reconstruction by titanium mesh-bone graft composite in pyogenic spinal infection: a long-term follow-up study

OBJECTIVE

Use of instrumentation in spinal osteomyelitis remains controversial because of the perceived risk of persistent infection related to a devitalized graft and spinal hardware. Particularly, limited information is available regarding the long-term follow-up of patients. We retrospectively reviewed the use of titanium mesh-bone graft composite after corpectomy in pyogenic spinal infection with a minimum 3-year follow-up outcome.

METHODS

Four patients, two men and two women, with cervical and thoracic myelopathy caused by cervical (two cases) and thoracic (two cases) osteomyelitis and epidural abscess, were treated. Their age ranged from 49 to 74 years (mean age 58 years). In one case, the coexisting medical condition was diabetes. Neurologic deficits caused by direct spinal cord compression due to epidural abscess, segmental deformity, and instability were observed in all cases. After infection was clinically controlled by intravenous antibiotics, anterior debridement and fusion using titanium mesh cage along with anterior plate were performed. Two-stage treatment was performed in two cases.

RESULTS

The postoperative course was uneventful; all patients experienced relief of symptoms. No evidence of recurrence or residual infection was observed in any patient during the average follow-up period of 42-56 months (average 49.0 months).

CONCLUSIONS

Once infection is clinically controlled, a titanium mesh-bone graft composite and plate in combination with aggressive debridement might provide an effective therapy for spinal osteomyelitis requiring surgery. Despite studying a small number of patients, we can conclude that titanium mesh reconstruction can be useful as a surgical method in selected low-risk patients with vertebral osteomyelitis.

Two-stage Management for Vertebral Osteomyelitis and Epidural Abscess: Technical Note

OBJECTIVE

The incidence of spinal infections has increased in recent years, and vertebral osteomyelitis and epidural abscess are issues of great concern for spine surgeons. We retrospectively reviewed our cases treated by two-stage management for vertebral osteomyelitis and epidural abscess.

METHODS

The series consisted of nine patients (five men and four women); their ages ranged from 49 to 77 years (mean age, 60.6 yr). Coexisting medical conditions were diabetes mellitus in one case and long-term steroid intake in another. Myelopathy or radicular pain was caused by osteomyelitis and an epidural abscess in all patients. Cervical, thoracic, and lumbar osteomyelitis was detected in three, four, and two patients, respectively; epidural abscess was pyogenic in four patients, tuberculous in three, and unknown in two patients. Our surgical strategy involved anterior debridement or drainage and application of an external orthosis postoperatively during the first stage. After clinical control of the infection by using organism-specific intravenous antibiotics as far as possible, as confirmed by normal erythrocyte sedimentation rate and/or C-reactive protein, second stage surgery was performed. This included complete debridement of all necrotic bone and soft tissues, and stable reconstruction with or without instrumentation (six and three patients, respectively).

RESULTS

The postoperative course was uneventful with relief of the symptoms after the second surgery. No evidence of recurrence or residual infection was observed in any patient, as shown by erythrocyte sedimentation rate and/or C-reactive protein levels during a follow-up period averaging 26.6 months (range, 2-56 mo).

CONCLUSION

Without denying the efficacy of the single-stage surgery, two-stage management can be a reasonable alternative for carefully selected patients who have spinal infection.

Treatment of a chronic Scedosporium apiospermum vertebral osteomyelitis

Scedosporium apiospermum is a rare cause of fungal vertebral osteomyelitis that may result in chronic infection requiring multiple surgical interventions and long-term medical therapy. This case is the seventh one reported in the literature and is the first to include salvage surgery of a previous major spinal reconstruction. This report is also the first to describe the use of the new antifungal agent voriconazole. In treating this case of chronic vertebral osteomyelitis, several principles are emphasized from both the surgical and medical perspectives. From a surgical perspective, the use of salvage surgery, temporary avoidance of spinal instrumentation, and an appropriate choice of graft materials are emphasized. From a medical perspective, confirmation of the diagnosis, the need for long-term antifungal therapy, the need for long-term patient compliance, and the use of the new antifungal agent voriconazole are emphasized. Application of these principles has led to an adequate 2-year outcome.

Use of folded vascularized rib graft in anterior fusion after treatment of thoracic and upper lumbar lesions. Technical note

For lesions involving the anterior and/or middle column of the spine, an anterior approach is adequate for curetting the lesion and restoring spinal stability. Materials such as autogenous bone grafts, cages with bone chips, some artificial materials, or allografts are used as strut materials. Rib material is usually removed when the anterior approach is conducted for thoracic or thoracolumbar lesions. A rib itself is not rigid enough to support the load, and a bone union is not easily obtained. The purpose of this paper is to describe a method of grafting vascularized rib in folded form to fill the defects left after removal of a spinal lesion. The rib, with the artery and vein at two levels cranial to the involved vertebral body, was isolated from surrounding tissues such as the intercostal nerve, muscles, and pleura. After curetting the lesion, the rib was folded into three or four pieces to a length adequate to fill the defect and inserted as a pedicled vascularized graft. A total of 23 cases, including 14 men and nine women, underwent surgery in which this grafting technique was used. The pathological conditions requiring anterior decompression and fusion were spinal trauma in nine cases, spinal infection in six cases, osteoporotic fracture in seven cases, and spinal metastasis in one case. In all cases a solid bone union was obtained and all infections resolved. With vascularized rib graft folded into three to four pieces, solid bone union can be obtained without use of any other grafted materials even in cases of infection and osteoporosis.