Percutaneous vertebral body cement augmentation for back pain related to occult osteomyelitis/diskitis

Vertebral augmentation-related Clostridium septicum osteomyelitis

We present a case of vertebral osteomyelitis following multiple vertebral augmentations in a patient with an insidious presentation. Vertebral augmentation (kyphoplasty and/or vertebroplasty) is a minimally invasive procedure that has become a fairly common and highly effective method in treating compression fractures. A large majority of patients that undergo this procedure suffer from osteoporosis. Numerous studies have shown that patients who undergo the procedure obtain substantial pain relief and improve functional status, often times to a greater extent than other surgical and nonsurgical management. Although its prevalence is low, infection after vertebral augmentation can be a serious consequence of the procedure. Blood cultures in this case were positive for Clostridium septicum. C septicum is a gram-positive, spore forming bacteria that is part of the normal gut flora in humans and is commonly associated with GI malignancy, necrosis, and inflammation. The patient did not respond to long-term intravenous antibiotics and required vertebral corpectomy and debridement with instrumentation. Vertebral body cultures obtained intraoperatively were positive for C septicum. It was noted historically that the patient had a hemorrhoidectomy 4 weeks prior to her initial fracture presentation. Although the risk of infection after vertebral augmentation is low, it is imperative that careful pre- and postoperative evaluation as well as follow-up is completed in order to prevent catastrophic consequences for patients. In patients with recent gastrointestinal tract manipulation/surgery, appropriate antibiotic prophylaxis should be considered prior to vertebral augmentation 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.

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.

Infection following percutaneous vertebral augmentation with polymethylmethacrylate

Although the incidence of infection following vertebroplasty or kyphoplasty is rare, postoperative infection and cement augmentation in preexistent spondylitis can cause life-threatening complications in frail patients with notable comorbidities. In such cases, urgent culture and biopsy and the long-term use of proper antibiotics are necessary.

PURPOSE

Infection following vertebral augmentation with polymethylmethacrylate (PMMA) is rare. We aimed to analyze 11 cases of pyogenic spondylitis and spondylodiscitis that occurred after vertebroplasty or kyphoplasty and to review similar cases in the literature.

METHODS

All cases of postoperative spinal infections in our institution between January 2005 and November 2016 that primarily underwent percutaneous vertebroplasty or kyphoplasty were retrospectively reviewed. Eleven patients (mean age 76.3 years) were included.

RESULTS

The incidence of infection following vertebroplasty/kyphoplasty was 0.36%. Postoperative infection occurred in 3 of 826 cases. All patients underwent combined surgical and antibiotic treatment because of neurologic deficit on the initial diagnosis of the infection or failure of prior medical treatment of the infection. The surgical procedure was thorough debridement of infected tissue and material including PMMA following anterior column reconstruction via anterior/posterior/combined approach in 10 patients and percutaneous pedicle screw fixation alone in 1 patient aged 96 years. The mean follow-up period was 21.1 months after the revision operation, excluding one patient who died 17 days after revision surgery. Ten patients recovered from infection.

CONCLUSIONS

Although the incidence of infection following vertebroplasty or kyphoplasty is rare, postoperative infection and cement augmentation in preexisting spondylitis can develop into a life-threatening complication in frail patients with notable comorbidities. In treating infected vertebroplasty and kyphoplasty, immediate culture and biopsy and the long-term use of proper antibiotics are critical. Prompt surgical treatment should be considered in case of significant neurologic deficit, severe instability due to infected fracture, and resistance to antibiotics.

Clinical effect evaluation of percutaneous vertebroplasty combined with the spinal external fixator for the treatment of osteoporotic compressive fractures with posterior vertebral defect

PURPOSE

The purpose of this study is to report a new technique and assess clinical outcome of compressive fractures with posterior vertebral defect treated by percutaneous vertebroplasty combined with the spinal external fixator.

METHOD

80 patients (32 males and 48 females), ranging from 62 to 88 years old with the mean age of 71.5 years, underwent surgery for the compressive fractures with posterior vertebral defect by percutaneous vertebroplasty combined with the spinal external fixator. All patients were diagnosed to have fresh compressive fractures with osteoporosis and posterior vertebral defect shown on roentgenograms, computed tomography scans or magnetic resonance imaging preoperatively. They underwent spinal external fixation firstly to be fixed and restored, then to be carried out percutaneous vertebroplasty. The mean follow-up was 24 months (16-42 months). Spinal canal encroachment, spinal cobb angle and vertebral body height loss were measured to assess clinical outcome before and after surgery, at the final follow-up. The Visual Analogue Scale and Oswestry Disability Index were used for pain and functional assessment. In all cases, preoperative and postoperative radiographs and magnetic resonance imaging were obtained.

RESULTS

The average time of surgery was 88 min (75-115 min). The mean blood loss was 10 ml (6-12 ml) during surgery. The anterior height loss of vertebral body decreased significantly from 79.3 ± 11% before surgery to 8.0 ± 5.2% after surgery, and 7.6 ± 6.0% at the final follow-up. The spinal canal encroachment significantly reduced from 19.9 ± 2.6 % preoperatively to 4.0 ± 0.7% postoperatively, 4.1 ± 0.7% at the final follow-up. The Cobb angle was corrected from 25.8 ± 7.9° primarily to 8.2 ± 4.1° postoperatively, 7.8 ± 3.1° at the final follow-up. There were significant differences (p < 0.05) among them before and after the surgery. Postoperative VAS and Oswestry scores were both significantly different from the preoperative and follow-up (p < 0.05).

CONCLUSION

The preliminary results are encouraging, showing that the spinal external fixator combined with percutaneous vertebroplasty was a safe and effective method to treat the osteoporotic compressive fractures with posterior vertebral defect.