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Lindsay SE, Gehling H, Ryu WHA, Yoo J, Philipp T. Posterior Fixation Without Debridement for Vertebral Body Osteomyelitis and Discitis: A 10-Year Retrospective Review. Int J Spine Surg 2023; 17:771-778. [PMID: 37586747 PMCID: PMC10753329 DOI: 10.14444/8541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Surgical treatment of vertebral osteomyelitis, discitis, and epidural abscesses is indicated in the setting of failure of antibiotic therapy, neurological deficits, epidural abscess, or spinal instability/deformity. Historically, surgical treatment mandated aggressive debridement and spinal stabilization. However, there is growing evidence that direct debridement may not be necessary and may contribute to morbidity. The purpose of this study was to evaluate the efficacy of posterior instrumentation without debridement in treating spinal infections. METHODS A retrospective medical record review was performed to identify patients treated with posterior instrumentation for spontaneous spinal infections. Success of treatment was determined based on postoperative ambulatory status, surgical complications, and need for revision surgery. RESULTS Twenty-seven patients treated with posterior-only long-segmented rigid fixation without formal debridement of infected material were included. The most common indications for surgical intervention included spinal instability (67%), neurologic compromise (67%), and failure of prolonged antibiotic treatment (63%). There were no recurrent deep infections in 21 of 22 patients who had long-term follow-up. Four patients required revision surgery, and 3 additional patients requested elective hardware removal. Postoperatively, 70% were ambulatory with no assistive devices postoperatively. CONCLUSIONS Vertebral osteomyelitis/discitis are challenging medical problems. Single-stage long-segment fusion without formal debridement combined with antibiotics is effective in the management of spontaneous spinal infections. CLINICAL RELEVANCE The present study suggests that acute instrumentation without anterior debridement is associated with a resolution of infection and improvements in neurologic deficits in patient with spontaneous spine infections. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Sarah E Lindsay
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Hanne Gehling
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Won Hyung A Ryu
- Department of Neurosurgery, Oregon Health and Science University, Portland, OR, USA
| | - Jung Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Travis Philipp
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
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Maddy KS, Tigre JY, Lu VM, Costello MC, Errante EL, Levi AD, Burks SS. Influence of instrumentation type on outcomes after surgical management of spondylodiscitis: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-08065-w. [PMID: 38148366 DOI: 10.1007/s00586-023-08065-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE Spondylodiscitis refers to infection of the intervertebral disk and neighboring structures. Outcomes based on instrumentation type are not well reported in the literature, but are important in establishing guidelines for surgical management of spondylodiscitis. This study aims to clarify the effect of instrumentation material selection on clinical and radiographic outcomes in patients with spondylodiscitis. METHODS Studies that evaluated the use of polyetheretherketone (PEEK), titanium, allograft, and/or autologous bone grafts for spondylodiscitis were identified in the literature. Radiographic and clinical data were analyzed using a meta-analysis of proportions, with estimated risk and confidence intervals reported for our primary study outcomes. RESULTS Thirty-two retrospective studies totaling 1088 patients undergoing surgical management of spondylodiscitis with PEEK, TTN, allograft, and autologous bone graft instrumentation were included. There were no differences in fusion rates (p-interaction = 0.55) with rates of fusion of 93.4% with TTN, 98.6% with allograft, 84.2% with autologous bone graft, and 93.9% with PEEK. There were no differences in screw loosening (p-interaction = 0.52) with rates of 0.33% with TTN, 0% with allograft, 1.3% with autologous bone graft, and 8.2% with PEEK. There were no differences in reoperation (p-interaction = 0.59) with rates of 2.64% with TTN, 0% with allograft, 1.69% with autologous bone graft, and 3.3% with PEEK. CONCLUSIONS This meta-analysis demonstrates that the choice of instrumentation type in the surgical management of spondylodiscitis resulted in no significant differences in rate of radiographic fusion, screw loosening, or reoperation. Future comparative studies to optimize guidelines for the management of spondylodiscitis are needed.
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Affiliation(s)
- Krisna S Maddy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave Miami, Miami, FL, 33136, USA.
| | - Joseph Yunga Tigre
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave Miami, Miami, FL, 33136, USA
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave Miami, Miami, FL, 33136, USA
| | - Meredith C Costello
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave Miami, Miami, FL, 33136, USA
| | - Emily L Errante
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave Miami, Miami, FL, 33136, USA
| | - Allan D Levi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave Miami, Miami, FL, 33136, USA
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - S Shelby Burks
- Department of Neurological Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave Miami, Miami, FL, 33136, USA
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
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Campbell DH, Dowling TJ, Hah R, Alluri RK, Wang JC. Surgical strategies for spinal infections: A narrative review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100293. [PMID: 38162170 PMCID: PMC10757275 DOI: 10.1016/j.xnsj.2023.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 01/03/2024]
Abstract
The successful operative management of spinal infections necessitates a thoughtful approach. Ideal treatment combines the universal goals of any spine operation, which are decompression of the neural elements and stabilization of instability, with source control and eradication of infection. Techniques to treat infection have evolved independently and alongside advances in implant technology and surgical techniques. This review will seek to outline current thinking on approaches to both primary and secondary spinal infections.
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Affiliation(s)
- David H. Campbell
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Thomas J. Dowling
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Raymond Hah
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - R. Kiran Alluri
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
| | - Jeffrey C. Wang
- Department of Orthopedic Surgery, Keck School of Medicine, USC Spine Center, University of Southern California, Los Angeles, 1450 San Pablo St #5400, Los Angeles, CA 90033, United States
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Kubota G, Aoki Y, Sato Y, Sato M, Yoh S, Nakajima T, Inoue M, Takahashi H, Nakajima A, Eguchi Y, Orita S, Nakagawa K, Ohtori S. Unexpectedly rapid decrease in the size of a spinal epidural abscess after percutaneous posterior pedicle screw fixation without decompression surgery: a case report. Spinal Cord Ser Cases 2022; 8:77. [PMID: 35963854 PMCID: PMC9376079 DOI: 10.1038/s41394-022-00543-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/27/2022] [Accepted: 08/02/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Spondylodiscitis accompanying spinal epidural abscess is often treated with decompression surgery when there are neurological symptoms. We report a case of spondylodiscitis accompanying spinal epidural abscess with severe lower extremity pain that was successfully treated with percutaneous posterior pedicle screw fixation without decompression surgery. CASE PRESENTATION A 53-year-old man was admitted to our hospital with severe low back pain (LBP), lower extremity pain and numbness, and fever. Lumbar magnetic resonance imaging (MRI) revealed spondylodiscitis at L2-L3 and a small epidural abscess located ventrally in the spinal canal. Initially, the patient was treated conservatively with empirical antibiotics. However, the lower extremity symptoms worsened and the epidural abscess expanded cranially to the T12 level. Percutaneous pedicle screw fixation without decompression was performed thirty-three days after admission. Postoperatively, the LBP and lower extremity pain dramatically improved. A postoperative MRI performed one week post-operatively showed an unexpectedly rapid decrease in the size of the epidural abscess, although no decompression surgery was performed. Two months after surgery, the epidural abscess completely disappeared. At the final follow-up (five years postoperatively), no recurrence of epidural abscess was observed, and the patient had no symptoms or disturbance of activities of daily living. DISCUSSION This surgical strategy should be carefully selected for patients with spondylodiscitis with accompanying spinal epidural abscess who have lower extremity symptoms. The stabilising effect of pedicle screw fixation may be advantageous for controlling spinal infections. Percutaneous posterior pedicle screw fixation without decompression is an optional treatment for spondylodiscitis accompanying spinal epidural abscess.
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Affiliation(s)
- Go Kubota
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of Orthopaedic Surgery, Kubota Orthopaedic Clinic, Katori, Chiba, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan.
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan.
| | - Yusuke Sato
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Masashi Sato
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Satoshi Yoh
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Takayuki Nakajima
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of Orthopaedic Surgery, Oyumino Central Hospital, Chiba-city, Chiba, Japan
| | - Masahiro Inoue
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
- Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city, Chiba, Japan
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Hosameldin A, Hussein M, Abdelhalim E, Shehab M, Osman A. Surgical management of spontaneous thoracic and lumbar spondylodiscitis by fixation and debridement. Surg Neurol Int 2022; 13:44. [PMID: 35242410 PMCID: PMC8888297 DOI: 10.25259/sni_1236_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/18/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Spondylodiscitis could be considered one of the most disturbing challenges that face neurosurgeons due to variety of management strategies. The lumbar region was highly affected then dorsal region with higher percentage for lesion in L4/5 (25%) followed by T11/12 and L5/S1 (15%). In our study, we discuss the efficacy of debridement and fixation in cases of spontaneous thoracic and lumbar spondylodiscitis. Methods: This retrospective study included 40 patients with spontaneous thoracic or lumbar spondylodiscitis indicated for surgical intervention in the period from March 2019 to February 2021. All patients were subjected to thorough history taking, neurological examination, and investigations. The patients were operated on through posterior approach by debridement and posterior transpedicular screws fixation and fusion. Results: Clinical assessment early postoperative revealed 75% of cases showed full motor power and 20% showed improvement in motor power, for sensory assessment, 85% showed improvement, the mean visual analog scale (VAS) score was of 3.65 ± 0.87. After 3 months postoperatively, 95% of cases were full motor power with sensory and autonomic (sphincteric) improvement. The mean VAS score was 2.5 ± 0.68. After 6 months postoperative, the clinical assessment revealed that 95% of cases were full motor power with sensory manifestation improvement, and 95% of them were continent. The mean VAS score was 1±0.85. Culture results showed that 65% of samples were negative culture, 15% had methicillin-resistant Staphylococcus aureus, and 10% had Escherichia coli with a single case of Pseudomonas and another one of fungal (Candida albicans). Postoperative 90% of cases showed improvement in erythrocyte sedimentation rate results and 95% of cases showed improvement in C-reactive protein results. Conclusion: Management of spontaneous thoracic and lumbar spondylodiscitis by surgical debridement and posterolateral open transpedicular fixation seems to be effective and safe method despite the presence of infection. We found that the clinical condition of our patients showed significant improvement with this addressed approach.
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Affiliation(s)
- Ahmed Hosameldin
- Department of Neurosurgery, Fayoum University Hospitals, Fayoum University, Fayoum, Egypt
| | - Mohammed Hussein
- Department of Neurosurgery, Fayoum University Hospitals, Fayoum University, Fayoum, Egypt
| | - Ehab Abdelhalim
- Department of Neurosurgery, Cairo University, Cairo, Cairo, Egypt
| | - Mohammed Shehab
- Department of Neurosurgery, Cairo University, Cairo, Cairo, Egypt
| | - Ashraf Osman
- Department of Neurosurgery, Fayoum University Hospitals, Fayoum University, Fayoum, Egypt
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Martínez-Gutiérrez O, Peña-Martínez V, Camacho-Ortiz A, Vilchez-Cavazos F, Simental-Mendía M, Tamez-Mata Y, Acosta-Olivo C. Spondylodiscitis treated with freeze-dried bone allograft alone or combined with autograft: A randomized and blinded trial. J Orthop Surg (Hong Kong) 2021; 29:23094990211019101. [PMID: 34041968 DOI: 10.1177/23094990211019101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To compare the bone fusion of freeze-dried allograft alone versus freeze-dried allograft combined autograft in spinal instrumentation due to spondylodiscitis. METHODS A randomized prospective trial of patients with spondylodiscitis treated with surgical debridement and spinal fixation with freeze-dried bone allograft and autograft (Group 1) or freeze-dried bone allograft alone (Group 2) was performed. Patient follow-up was assessed with a CT-scan for bone fusion; consecutive serum inflammatory marker detection (C-reactive protein, [CRP], and erythrocyte sedimentation rate, [ESR]) and clinical assessment (pain, functional disability, and spinal cord injury recovery) were other outcome parameters. The primary outcome was the grade of bone allograft integration with the scale of Tan (which ranges from 1 to 4, with lower scores indicating a better fusion rate) at 1 year after surgery. RESULTS A total of 20 patients were evaluated, 13 (65%) men and 7 (35%) women with a mean age of 47.2 (±14.3) years. Homogeneous distribution of demographic data was observed. A similar satisfactory bone graft fusion grade was observed in both graft groups at 1 year after surgery (p = 1.0000). Serum inflammatory markers gradually decreased in both groups after surgical intervention (CRP, p < 0.001; ESR, p < 0.01). At one-year follow-up, gradual improvement of pain, functional disability, and neurological spinal injury recovery in both graft groups were achieved. CONCLUSION Freeze-dried allograft alone could be a therapeutic option for spinal fixation surgery due to spondylodiscitis since it achieves a satisfactory graft fusion rate and clinical improvement. LEVEL OF EVIDENCE Level 1. Treatment. REGISTER NCT03265561.
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Affiliation(s)
- Oscar Martínez-Gutiérrez
- 27771Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José E. González", Monterrey, Nuevo León, Mexico
| | - Victor Peña-Martínez
- 27771Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José E. González", Monterrey, Nuevo León, Mexico
| | - Adrián Camacho-Ortiz
- 27771Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José E. González", Monterrey, Nuevo León, Mexico
| | - Felix Vilchez-Cavazos
- 27771Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José E. González", Monterrey, Nuevo León, Mexico
| | - Mario Simental-Mendía
- 27771Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José E. González", Monterrey, Nuevo León, Mexico
| | - Yadira Tamez-Mata
- 27771Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José E. González", Monterrey, Nuevo León, Mexico
| | - Carlos Acosta-Olivo
- 27771Universidad Autónoma de Nuevo León, Facultad de Medicina, Hospital Universitario "Dr. José E. González", Monterrey, Nuevo León, Mexico
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Pojskić M, Carl B, Schmöckel V, Völlger B, Nimsky C, Saβ B. Neurosurgical Management and Outcome Parameters in 237 Patients with Spondylodiscitis. Brain Sci 2021; 11:brainsci11081019. [PMID: 34439638 PMCID: PMC8394582 DOI: 10.3390/brainsci11081019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 12/19/2022] Open
Abstract
Surgical treatment of spondylodiscitis allows for rapid mobilization and shortens hospital stays, which makes surgical treatment the first-line therapy. We aim to describe our experiences with operative treatment on spondylodiscitis and to determine the parameters that are important in the prediction of outcomes. A retrospective review identified 237 patients who were operatively treated for spondylodiscitis in our institution between January 2010 and December 2018. Clinical data were collected through review of electronic records and relevant imaging. In all cases, contrast-enhancing MRI from the infected region of the spine was obtained. Leukocyte count and C-reactive protein concentrations (CRP) were determined in all the patients. We included 237 patients in the study, 87 female (36.7%) and 150 male (63.3%), with a mean age of 71.4 years. Mean follow-up was 31.6 months. Forty-five patients had spondylodiscitis of the cervical, 73 of the thoracic, and 119 of the lumbosacral spine. All the patients with spondylodiscitis of the cervical spine received instrumentation. In thoracic and lumbar spine decompression, surgery without instrumentation was performed in 26 patients as immediate surgery and in a further 28 patients in the early stages following admission, while 138 patients received instrumentation. Eighty-nine patients (37.6%) had concomitant infections. Infection healing occurred in 89% of patients. Favorable outcomes were noted in patients without concomitant infections, with a normalized CRP value and in patients who received antibiotic therapy for more than six weeks (p < 0.05). Unfavorable outcomes were noted in patients with high CRP, postoperative spondylodiscitis, and recurrent spondylodiscitis (p < 0.05). Application of antibiotic therapy for more than six weeks and normalized CRP showed a correlation with favorable outcomes, whereas concomitant infections showed a correlation with unfavorable outcomes. A detailed screening for concomitant infectious diseases is recommended.
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Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (B.C.); (V.S.); (B.V.); (C.N.); (B.S.)
- Correspondence: ; Tel.: +49-64215869848
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (B.C.); (V.S.); (B.V.); (C.N.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 65199 Marburg, Germany
- Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, 65199 Wiesbaden, Germany
| | - Vincent Schmöckel
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (B.C.); (V.S.); (B.V.); (C.N.); (B.S.)
| | - Benjamin Völlger
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (B.C.); (V.S.); (B.V.); (C.N.); (B.S.)
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (B.C.); (V.S.); (B.V.); (C.N.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 65199 Marburg, Germany
| | - Benjamin Saβ
- Department of Neurosurgery, University of Marburg, 65199 Marburg, Germany; (B.C.); (V.S.); (B.V.); (C.N.); (B.S.)
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Carballo Cuello CM, Fernández-de Thomas RJ, De Jesus O, De Jesús Espinosa A, Pastrana EA. Prevention of Surgical Site Infection in Lumbar Instrumented Fusion Using a Sterile Povidone-Iodine Solution. World Neurosurg 2021; 151:e700-e706. [PMID: 33940260 DOI: 10.1016/j.wneu.2021.04.094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgical site infection (SSI) is a well-documented complication in patients who undergo posterior spine instrumentation with most studies reporting an incidence of 1%-12%. Some studies have documented that a diluted sterile povidone-iodine (PVI) solution can be safely used in posterior spinal fusion surgeries as an antiseptic; in this study, we analyzed its effectiveness in reducing SSI. METHODS This retrospective study consisted of consecutive patients who underwent elective posterior lumbar instrumentation performed by a single surgeon from 2016 to 2019. In the first 134 patients, wounds were irrigated before arthrodesis and closure with 1 L of 0.9% normal saline solution; in the subsequent 144 patients, wound irrigation was with a solution of 35 mL of sterile 10% PVI. Both groups were analyzed to determine if wound irrigation with sterile PVI solution decreased SSIs. RESULTS There were 9 (6.7%) SSIs in the 0.9% normal saline solution group versus 1 (0.7%) SSI in the PVI group (P = 0.008). PVI solution had a relative risk for SSI of 0.093 (P = 0.008) and an adjusted odds ratio of 0.113 (P = 0.05). Increased body mass index and posterolateral spine fusion with laminectomy were significant risk factors for SSI (P = 0.04 and P = 0.030, respectively). CONCLUSIONS Wound irrigation with PVI solution significantly reduced SSI in elective posterior lumbar instrumentation cases. Subgroup analysis provided significant results to recommend use of PVI solution for SSI prevention, particularly in overweight and obese patients. We also recommend its use in patients with risk factors for SSI, such as longer operative time and unintended durotomy.
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Affiliation(s)
- César M Carballo Cuello
- Neurosurgery Section, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | | | - Orlando De Jesus
- Neurosurgery Section, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Aixa De Jesús Espinosa
- Neurosurgery Section, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | - Emil A Pastrana
- Neurosurgery Section, Department of Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico.
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9
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Mohamed AA, Soffar HM, El Zayat HH, Aboul-Ela HM. Prognosis of spinal infections managed by minimal debridement: A case series in two tertiary centers. Surg Neurol Int 2021; 12:83. [PMID: 33767887 PMCID: PMC7982097 DOI: 10.25259/sni_29_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/13/2021] [Indexed: 12/18/2022] Open
Abstract
Background Spinal infections can be challenging in their management and include spondylitis, epidural abscess, and spondylodiscitis. Usual treatment is conservative through antimicrobials or surgery to decompress neural tissue, debride all infected tissues, and fix if needed. We propose the concept of surgery without formal debridement aiming at neural protection. Methods The study was performed at two tertiary centers on 25 patients with clinical findings. One patient was treated conservatively and the rest surgically by laminectomy and fixation if needed. Evacuation of fluid pus was performed. In the cervical and the thoracic region, if the granulation tissue was anterior to the cord, only decompression by laminectomy was done. Results Low back pain was present in 22 cases (88%), 16 cases (64%) had lower limb pain, and 12 cases (48%) had weakness. The level of spinal infection was lumbar in 15 cases (60%), thoracic in 9 cases (36%) cases, and cervical in 1 case (4%). The type of infection was epidural abscess in 20 cases (80%), discitis in 16 cases (64%), and vertebral osteomyelitis in 12 cases (48%). Laminectomy was performed in 20 cases (80%) and fixation in 17 cases (68%). The symptoms improved in all cases. On follow-up, the lesion was reduced in 14 patients (56%) and disappeared in 11 cases (44%). One case required ventriculoperitoneal shunt placement due to postinfectious hydrocephalus. Conclusion Dealing with spinal infections surgically through decompression or fixation with minimal debridement of infected tissue appears to be a safe and effective method of management.
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Affiliation(s)
- Ahmed Ali Mohamed
- Department of Neurosurgery, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | | | - Hazem Hassan El Zayat
- Department of Neurosurgery, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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10
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Posterior stabilisation without formal debridement for the treatment of non-tuberculous pyogenic spinal infection in frail and debilitated population - A systematic review and meta-analysis. J Clin Orthop Trauma 2020; 15:9-15. [PMID: 33717910 PMCID: PMC7920149 DOI: 10.1016/j.jcot.2020.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/14/2020] [Accepted: 11/12/2020] [Indexed: 11/20/2022] Open
Abstract
Non-tuberculous pyogenic spinal infection (PSI) incorporates a variety of different clinical conditions. Surgical interventions may be necessary for severe cases where there is evidence of spinal instability or neurological compromise. The primary surgical procedure, for late-stage PSI, focuses on the anterior approach with aggressive debridement of the infected tissue regions. An alternative treatment method that employs a posterior approach without any formal debridement, is seen as controversial. To the best of our knowledge, few case series and no systematic reviews are assessing the value of this posterior technique. We aim to evaluate the effectiveness of the posterior approach without formal debridement and the associated clinical outcomes, for PSI cases requiring surgical intervention. Several databases including MEDLINE, NHS Evidence, and the Cochrane database were searched from the date of creation of each database to December 16, 2019. A selection of the keywords used includes: "posterior approach", "debridement" and "discitis". Studies were excluded if they involved the anterior approach, carried out formal debridement, or were tuberculous spinal infection cases. We accepted any study type which included adult patients, with spinal infection at any level of the vertebral column. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used to follow standard systematic review structure. The main clinical outcomes evaluated include pain, neurological recovery (Frankel Grading System, FGS) post-operative complications, and functional outcomes (Kirkaldy-Willis Criteria and Spine Tango Combined Outcome Measure Index, COMI). Post-surgical neurological improvement was demonstrated with a mean FGS improvement of 1.12 in 102 patients over the included four articles. Post-operative neurological function was found to be improved at a statistically significant level when a random-effects model was applied, with the effect size found to be at 0.68 (p < 0.001). Pain level was improved significantly postoperatively. There were also enhanced functional outcomes post-intervention when the Kirkaldy-Willis criteria and COMI scores were assessed in certain studies. Within the limit of the available literature, our results showed that the posterior approach with posterior stabilisation without formal debridement can result in successful infection resolution, improved pain scores and neurological outcomes. However, Larger series with longer follow-up duration is strongly recommended.
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Pingel A. [Spondylodiscitis]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 159:687-703. [PMID: 32851619 DOI: 10.1055/a-1129-9246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Spondylodiscitis is an infection of the spine that first affects the vertebral endplates ("spondylitis") and then spreads to the adjacent intervertebral disc ("spondylodiscitis"). As it is a potentially life-threatening systemic disease rapid, often surgical treatment is required. Due to the multimorbidity of the patients and the complexity of the therapy, a multidisciplinary approach is essential. The vast majority of the cases heals under conservative therapy. An absolute indication for surgical therapy is given for acute septic courses or if there are new relevant neurological deficits. In addition, urgent surgical treatment is required for epidural abscesses that can be diagnosed by means of magnetic resonance imaging. In developed countries, over 90% of all spondylodiscitis cases come to a complete recovery.
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Zhang CH, Zaidman N, Russo V. Hybrid Minimally Invasive Technique for Treatment of Thoracolumbar Spondylodiscitis and Vertebral Osteomyelitis. World Neurosurg 2020; 141:e752-e762. [PMID: 32526368 DOI: 10.1016/j.wneu.2020.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/31/2020] [Accepted: 06/02/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Spondylodiscitis and vertebral osteomyelitis cause significant morbidity and mortality, and typically occur in patients with multiple comorbidities. The use of minimally invasive spinal surgery in the previous decade has offered the advantages of reduced intraoperative blood loss and postoperative pain for patients. In the present report, we have described our experience with using a hybrid minimally invasive (HMI) technique (combining percutaneous fixation with a mini-open approach for decompression and debridement) for the treatment of thoracolumbar spondylodiscitis, reporting the patient demographics, intraoperative measures, and 12-month outcomes. METHODS The data from patients presenting to a tertiary referral neurosurgical center with thoracolumbar spondylodiscitis and osteomyelitis who had undergone HMI from 2016 to 2018 were retrospectively evaluated. Patient demographics, intraoperative factors, estimated blood loss, and immediate postoperative complications were recorded. The patient outcomes were evaluated using EuroQOL 5-dimension questionnaire and visual analog scale in the immediate postoperative period and at 12 months postoperatively. RESULTS A total of 13 patients were included in the present study, 12 with spontaneous infection and 1 with infection secondary to recent microdiscectomy at another institution. All the patients had systemic comorbidities with an American Society of Anesthesiologists class of ≥2. Of the 13 patients, 11 had pyogenic infections and 2 had spinal tuberculosis. The mean estimated blood loss was 546.2 mL. The mean time for patients to sit out of bed was 2.2 days, and the mean time to start mobilizing was 4.5 days. The EuroQOL 5-dimension questionnaire scores showed improvement in all modalities at 12 months postoperatively. CONCLUSIONS In our cohort, HMI was a safe and effective treatment of thoracolumbar spondylodiscitis, with the potential benefits of reduced blood loss, operative duration, and postoperative pain.
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Affiliation(s)
- Catherine Hao Zhang
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
| | - Nathalie Zaidman
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Vittorio Russo
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Abstract
In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 9 focused on implants questions in spine surgery, for which this article provides the recommendations, voting results, and rationales.
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Anterior Cervical Debridement and Fusion for Cervical Pyogenic Spondylodiscitis: Use of Anterior Cervical Plating or Not? Spine (Phila Pa 1976) 2020; 45:431-437. [PMID: 31651678 DOI: 10.1097/brs.0000000000003298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective multicenter case series. OBJECTIVE We sought to evaluate the safety and efficacy of anterior cervical plating in anterior cervical debridement and fusion (ACDF) for patients with cervical pyogenic spondylodiscitis (CPS). SUMMARY OF BACKGROUND DATA Due to concerns about bacterial seeding on the foreign material after instrumentations in pyogenic infections, the safety and efficacy of anterior cervical plating for CPS are still undetermined and controversial. Little information is available about the safety and efficacy of anterior cervical plating to manage CPS. METHODS Twenty-three patients who underwent ACDF with (n = 12) or without (n = 11) plating for CPS were included. The mean age was 62.6 years. Medical records were reviewed and radiological parameters including segmental height, segmental angle, C2-C7 angle, and fusion status were analyzed. The mean follow-up period after surgery was 21.3 months. RESULTS After ACDF with plating, segmental height, segmental angle, and C2-C7 angle were significantly improved compared with preoperative conditions and remained well-maintained at the last follow-up. After ACDF without plating, three radiological parameters were also initially improved compared with preoperative condition, but significantly deteriorated to preoperative levels at the time of the last follow-up. The fusion rate was higher in the ACDF with plating group compared with the ACDF without plating group (90.9% vs. 63.6%; P < 0.01). One patient who received ACDF with plating and four patients who received ACDF without plating underwent revision surgery due to nonunion or bone graft dislodgement. No recurrence of pyogenic spondylodiscitis occurred in either group. CONCLUSION ACDF with plating showed better surgical outcomes compared with ACDF without plating for CPS. We recommend the use of anterior cervical plating, which can provide biomechanical stability, for better healing of CPS. To our knowledge, this is the largest surgical case series of CPS. LEVEL OF EVIDENCE 4.
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Dobran M, Iacoangeli M, Scortichini AR, Mancini F, Benigni R, Nasi D, Gladi M, Scerrati M. Spontaneous chronic subdural hematoma in young adult: the role of missing coagulation facto. G Chir 2019; 38:66-70. [PMID: 28691669 DOI: 10.11138/gchir/2017.38.2.066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Chronic subdural hematoma (CSDH) is typically in elderly and rarely in young people. To prevent complications and re-bleeding after surgical treatment of CSDH it is important to assess the risk factors as coagulation disorders especially in young patients (below 65 years) with no history of head trauma, alcohol abuse or anticoagulant therapy. PATIENTS AND METHODS This study consists of 16 patients (12 males, 4 females) with age ranging from 27 to 59 years (median 48,25 years) operated for CSDH. All patients are submitted to routine coagulation parameters pre-operatively and complete screening for unknown coagulation deficit in the follow-up. RESULTS Factor VII was altered in 6 out of 16 patients and one patient had the alteration of the Von Willebrand factor. Recurrence occurred in 4 out of 16 patients and all of these patients were positive for factor VII deficiency. Three pts were in therapy with ASA. No patients were alcoholists or suffered from hematological disease. CONCLUSION In this study we documented that the decreased activity of VII factor may play a role in the pathophysiology and recurrence of spontaneous CSDH in young adults. We suggest that for young patients aged under 65 y.o. suffered from CSDH the screening of coagulation factors is useful to planning a safely and correct surgical therapy.
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Dobran M, Marini A, Nasi D, Liverotti V, Benigni R, Costanza MD, Mancini F, Scerrati M. Clinical Outcome of Patients Over 90 Years of Age Treated for Chronic Subdural Hematoma. J Korean Neurosurg Soc 2019; 65:123-129. [PMID: 31064037 PMCID: PMC8752881 DOI: 10.3340/jkns.2018.0011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/17/2018] [Indexed: 11/27/2022] Open
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The Incidence of Adjacent Segment Degeneration after the Use of a Versatile Dynamic Hybrid Stabilization Device in Lumbar Stenosis: Results of a 5-8-Year Follow-up. Asian Spine J 2018; 12:263-271. [PMID: 29713407 PMCID: PMC5913017 DOI: 10.4184/asj.2018.12.2.263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 09/07/2017] [Accepted: 09/11/2017] [Indexed: 12/26/2022] Open
Abstract
Study Design Retrospective study with long-term follow-up. Purpose To evaluate the long-term incidence of adjacent segment degeneration (ASD) and clinical outcomes in a consecutive series of patients who underwent spinal decompression associated with dynamic or hybrid stabilization with a Flex+TM stabilization system (SpineVision, Antony, France) for lumbar spinal stenosis. Overview of Literature The incidence of ASD and clinical outcomes following dynamic or hybrid stabilization with the Flex+TM system used for lumbar spinal stenosis have not been well investigated. Methods Twenty-one patients with lumbar stenosis and probable post-decompressive spinal instability underwent decompressive laminectomy followed by spinal stabilization using the Flex+TM stabilization system. The indication for a mono-level dynamic stabilization was a preoperative magnetic resonance imaging (MRI) demonstrating evidence of severe disc disease associated with severe spinal stenosis. The hybrid stabilization (rigid-dynamic) system was used for multilevel laminectomies with associated initial degenerative scoliosis, first-grade spondylolisthesis, or rostral pathology. Results The improvement in Visual Analog Scale and Oswestry Disability Index scores at follow-up were statistically significant (p<0.0001 and p<0.0001, respectively). At the 5–8-year follow-up, clinical examination, MRI, and X-ray findings showed an ASD complication with pain and disability in one of 21 patients. The clinical outcomes were similar in patients treated with dynamic or hybrid fixation. Conclusions Patients treated with laminectomy and Flex+TM stabilization presented a satisfactory clinical outcome after 5–8 years of follow-up, and ASD incidence in our series was 4.76% (one patient out of 21). We are aware that this is a small series, but our long-term follow-up may be sufficient to contribute to the expanding body of literature on the development of symptomatic ASD associated with dynamic or hybrid fixation.
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A Case of Nongerminomatous Germ Cell Tumor of the Pineal Region: Risks and Advantages of Biopsy by Endoscopic Approach. Case Rep Med 2018; 2018:5106701. [PMID: 29713348 PMCID: PMC5866897 DOI: 10.1155/2018/5106701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/30/2018] [Accepted: 02/15/2018] [Indexed: 01/04/2023] Open
Abstract
A 21-year-old male was admitted to our department with headache and drowsiness. CT scan and MRI revealed acute obstructive hydrocephalus caused by a pineal region mass. The serum and CSF levels of beta-human chorionic gonadotropin (beta-hCG) were 215 IU/L and 447 IU/L, respectively, while levels of alpha-fetoprotein (AFP) were normal. A germ cell tumor (GCT) was suspected, and the patient underwent endoscopic third ventriculostomy (ETV) with biopsy. After four days from surgery, the tumor bled with mass expansion and ETV stoma occlusion; thus, a ventriculoperitoneal shunt was positioned. After ten months, the tumor metastasized to the thorax and abdomen with progression of intracerebral tumor mass. Despite the aggressive nature of this tumor, ETV remains a valid approach for a pineal region mass, but in case of GCT, the risk of bleeding should be taken into account, during and after the surgical procedure.
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Dobran M, Marini A, Nasi D, Liverotti V, Benigni R, Iacoangeli M, Scerrati M. Surgical treatment and outcome in patients over 80 years old with intracranial meningioma. Clin Neurol Neurosurg 2018. [PMID: 29518711 DOI: 10.1016/j.clineuro.2018.02.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Study of mortality rate and clinical outcomes in octogenarians patients operated for intracranial meningiomas. PATIENTS AND METHODS Clinical, radiological and surgical data of 25 elderly patients aging over 80 years old operated at our Department from 2013 to 2016 for intracranial meningiomas have been recorded and analyzed. One-month mortality and clinical outcome at six-months after surgery were evaluated. Logistic regression was used for detecting the risk factors influencing mortality and neurological functions. RESULTS The median age at diagnosis was 8185 years (range 80-87). Meningiomas were gross-total removed in 18 cases out of 25 (72%) and partially resected in 7 (28%). One-month post-operative mortality occurred in 2 pts out of 25 (8%). A close correlation was found between operative duration over 240 min and mortality (p = 0,0421). There was a significantly lower mortality in patients with ASA II rather than in patients with ASA III (p = 0,038). The median pre-operative KPS value was 743 (range 50-90) while at six-month follow-up was 82. The surgical time (p = 00,006) and size of the lesion >4 cm (p = 002) were a significant prognostic factors for clinical improvement at six-month follow-up. CONCLUSIONS The operative time and the ASA score are the most important prognostic factors for the mortality and neurological outcome of elderly patients over 80 years old operated for intracranial meningioma. Even if the number of patients is limited, our findings suggest that, after a careful preoperative stratification in elderly patients, it is possible to remove an intracranial meningioma with good results.
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Affiliation(s)
- Mauro Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy.
| | - Alessandra Marini
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Valentina Liverotti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Roberta Benigni
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
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Dobran M, Nasi D, Chiriatti S, Gladi M, Somma LD, Iacoangeli M, Scerrati M. Prognostic Factors in Glioblastoma: Is There a Role for Epilepsy? Neurol Med Chir (Tokyo) 2018; 58:110-115. [PMID: 29343677 PMCID: PMC5929919 DOI: 10.2176/nmc.oa.2017-0167] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The prognostic relevance of epilepsy at glioblastoma (GBMs) onset is still under debate. In this study, we analyzed the value of epilepsy and other prognostic factors on GBMs survival. We retrospectively analyzed the clinical, radiological, surgical and histological data in 139 GBMs. Seizures were the presenting symptoms in 50 patients out of 139 (35.9%). 123 patients (88%) were treated with craniotomy and tumor resection while 16 (12%) with biopsy. The median overall survival was 9.9 months from surgery. At univariable Cox regression, the factors that significantly improved survival were age less than 65 years (P = 0.0015), focal without impairment of consciousness seizures at presentation (P = 0.043), complete surgical resection (P < 0.001), pre-operative Karnofsky performance status (KPS) > 70 (P = 0.015), frontal location (P < 0.001), radiotherapy (XRT) plus concomitant and adjuvant TMZ (P < 0.001). A multivariable Cox regression showed that the complete surgical resection (P < 0.0001), age less than 65 years (P = 0.008), frontal location (P = 0.0001) and XRT adjuvant temozolomide (TMZ) (P < 0.0001) were independent factors on longer survival. In our series epilepsy at presentation is not an independent prognostic factor for longer survival in GBM patients. Only in the subgroup of patients with focal seizures without impairment of consciousness, epilepsy was associated with an increased significant overall survival at univariate analysis (P = 0.043). Main independent factors for relatively favorable GBMs outcome are complete tumor resection plus combined XRT-TMZ, frontal location and patient age below 65 years old.
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Affiliation(s)
- Mauro Dobran
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital
| | - Davide Nasi
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital
| | - Stefano Chiriatti
- Department of Neurosurgery, Azienda Ospedaliera per l'Emergenza Cannizzaro
| | - Maurizio Gladi
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital
| | - Lucia di Somma
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital
| | - Massimo Scerrati
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital
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Di Rienzo A, Brunozzi D, Dobran M, Iacoangeli M, Colasanti R, Trivedi R, Scerrati M. Skip Hemilaminectomy for Large, Multilevel Spinal Epidural Hematomas: Report of a Series of 11 Patients. World Neurosurg 2018; 111:e933-e940. [PMID: 29325946 DOI: 10.1016/j.wneu.2018.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/31/2017] [Accepted: 01/04/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We present our experience with a modification of the conventional techniques for the removal of large spinal epidural hematomas (SEHs), based on multilevel "skip hemilaminectomies." METHODS Eleven patients with SEHs extending over 5 or more spinal segments were treated at our institution via a modified hemilaminectomy technique from 2008 to 2014. This procedure, that we called "skip hemilaminectomy," consists in performing consecutive, alternating, unilateral laminar decompressions at 2-3 levels, followed by sublaminar undercutting, ipsi- and contralateral flavectomy, plus hematoma removal. RESULTS Complete clot evacuation and full neurologic recovery were always achieved. A short hospital stay, fast postoperative mobilization, a minimized need of analgesic drugs, and no complications were recorded. CONCLUSIONS In our preliminary experience, skip hemilaminectomy seems to be as safe as more conventional techniques (laminectomy, extended hemilaminectomy) for the removal of large multilevel SEHs, granting full neurologic improvement, short surgical times-even for very large lesions-and no complications at follow-up.
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Affiliation(s)
| | - Denise Brunozzi
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
| | - Roberto Colasanti
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy.
| | - Rikin Trivedi
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Massimo Scerrati
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
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Clinical and psychological outcome after surgery for lumbar spinal stenosis: A prospective observational study with analysis of prognostic factors. Neurol Neurochir Pol 2017; 52:70-74. [PMID: 29246564 DOI: 10.1016/j.pjnns.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 12/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The identification of psychological risk factors is important for the selection of patients before spinal surgery. Moreover, the effect of surgical decompression in lumbar spinal stenosis (LSS) on psychological outcome is not previously well analyzed. AIM OF PAPER to investigate clinical and psychological outcome after surgery for LSS and the effect of depressive symptoms and anxiety on the clinical outcome. MATERIALS AND METHODS A total of 25 patients with symptomatic LSS underwent decompressive surgery with or without spinal stabilization were prospectively enrolled in this observational surgery. The Symptom Checklist-90-Revised (SCL-90-R) was used to assess global psychological distress with a summary score termed Global Severity Index (GSI) and single psychological disorders including depression (DEP) and anxiety (ANX). The clinical outcome of surgery was evaluated with the Oswestry Disability Index (ODI) and visual analogue scale (VAS) pain assessment. RESULTS Compared with baseline, there was a statistically significant improvement in VAS, ODI and GSI after surgery (p<0.05) in all patients. Univariate analysis revealed that patients with high GSI and anxiety and depression scores had significantly higher ODI and VAS scores in the follow-up with a bad outcome. CONCLUSIONS Surgery for spinal stenosis was effective to treat pain and disability. In this prospective study baseline global psychological distress, depression and anxiety were associated with poorer clinical outcome.
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Dobran M, Benigni R, Nasi D, Cantoro D. Penile Mondor's disease after anterolateral retroperitoneal approach for lumbar fracture. BMJ Case Rep 2017; 2017:bcr-2017-220790. [PMID: 29092965 PMCID: PMC5695466 DOI: 10.1136/bcr-2017-220790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This is a rare case of thrombosis of the dorsal vein of the penis (Mondor’s disease) occurred after an anterior-lateral retroperitoneal approach for a vertebral stabilisation in thoracolumbar vertebral fracture. Potential causes are traumatism, neoplasms, excessive sexual activity or abstinence. Although penile Mondor’s disease is a clinical diagnosis, ultrasound imaging is the gold standard to confirm it. In the reported case, 1 week after neurosurgical retroperitoneal procedure of vertebral stabilisation, the patient complained of a painful cord-like mass midshaft of penis. The diagnosis was made by clinical evaluation and ultrasound images. After 2 weeks of therapy with enoxaparin sodium, the patient recovered. The authors report this case evaluating the possible correlation between the anterior-lateral retroperitoneal approach and the development of the rare Mondor’s disease.
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Affiliation(s)
- Mauro Dobran
- Neurosurgery, Neurosurgery, Ancona, Italy, Italy
| | | | - Davide Nasi
- Neurosurgery, Neurosurgery, Ancona, Italy, Italy
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Dobran M, Marini A, Nasi D, Gladi M, Liverotti V, Costanza MD, Mancini F, Scerrati M. Risk factors of surgical site infections in instrumented spine surgery. Surg Neurol Int 2017; 8:212. [PMID: 28970960 PMCID: PMC5613592 DOI: 10.4103/sni.sni_222_17] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 07/06/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The incidence of wound infections associated with instrumented spine surgery ranges from 2 to 20%. These complications may lead to poor outcomes. Knowing the risk factors associated with surgical site infections (SSI) after utilizing spinal implants is essential to avoid these complications, including hardware removal. METHODS We reviewed retrospectively 550 patients who underwent spinal fusion surgery from 2011 to 2015; 16 developed SSI after spinal instrumentation. The diagnosis of SSI was established based on positive wound swab or blood cultures, and various clinical, laboratory, and radiological findings. Additional preoperative and intraoperative risk factors were analyzed. RESULTS The incidence of SSI after spinal instrumentation surgery was 2.9%. Obesity was a statistically significant parameter (P = 0.013) that contributed to SSI along with the alcoholism and/or drug abuse (P = 0.034); use of a Foley catheter nearly reached significance levels. CONCLUSIONS There is an increased risk of SSI in patients who are obese or use drugs and/or alcohol. Clear preoperative identification of these risk factors prior to implanting spinal instrumentation should help prevent SSI in the future.
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Affiliation(s)
- M. Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - A. Marini
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D. Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M. Gladi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - V. Liverotti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M. Della Costanza
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - F. Mancini
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M. Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
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Dobran M, Brancorsini D, Costanza MD, Liverotti V, Mancini F, Nasi D, Iacoangeli M, Scerrati M. Epidural scarring after lumbar disc surgery: Equivalent scarring with/without free autologous fat grafts. Surg Neurol Int 2017; 8:169. [PMID: 28840073 PMCID: PMC5551283 DOI: 10.4103/sni.sni_142_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/28/2017] [Indexed: 11/17/2022] Open
Abstract
Background: To limit epidural fibrosis and prevent scar formation/nerve tethering that may contribute to chronic postoperative pain; some surgeons have utilized epidural autologous fat grafts following lumbar microdiscectomy. Methods: We investigated the correlation between post-microdiscectomy epidural scarring [including select magnetic resonance imaging (MRI) studies] and clinical outcomes in 36 patients operated for symptomatic. MRI documented L4-L5 and L5-S1 disk herniations with (18 patients) and without (18 patient) the application of free fat grafts. In addition, histological evaluation of the original fat grafts was performed in 4 patients requiring additional surgery. Results: We found no clear association between the use of autologous graft fats and the clinical outcomes in this study. Conclusion: In this preliminary study involving only 36 patients, the prospective randomized use of free autologous fat grafts did not appear to influence outcomes following microdiscectomy.
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Affiliation(s)
- M Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D Brancorsini
- Department of Pathological Anatomy, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Della Costanza
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - V Liverotti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - F Mancini
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
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Dobran M, Mancini F, Nasi D, Scerrati M. A case of deep infection after instrumentation in dorsal spinal surgery: the management with antibiotics and negative wound pressure without removal of fixation. BMJ Case Rep 2017; 2017:bcr-2017-220792. [PMID: 28756380 PMCID: PMC5623226 DOI: 10.1136/bcr-2017-220792] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Until today the role of spinal instrumentation in the presence of a wound infection has been widely discussed and recently many authors leave the hardware in place with appropriate antibiotic therapy. This is a case of a 65-year-old woman suffering from degenerative scoliosis and osteoporotic multiple vertebral collapses treated with posterior dorsolumbar stabilisation with screws and rods. Four months later, skin necrosis and infection appeared in the cranial wound with exposure of the rods. A surgical procedure of debridement of the infected tissue and package with a myocutaneous trapezius muscle flap was performed. One week after surgery, negative pressure wound therapy was started on the residual skin defect. The wound healed after 2 months. The aim of this case report is to focus on the utility of this method even in the case of hardware exposure and infection. This may help avoid removing instrumentation and creating instability.
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Affiliation(s)
- Mauro Dobran
- Department of Neurosurgery, Umberto I General Hospital, Ancona, italy, Italy
| | - Fabrizio Mancini
- Department of Neurosurgery, Umberto I General Hospital, Ancona, italy, Italy
| | - Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Ancona, italy, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Ancona, italy, Italy
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DOBRAN M, MARINI A, GLADI M, NASI D, COLASANTI R, BENIGNI R, MANCINI F, IACOANGELI M, SCERRATI M. Deep spinal infection in instrumented spinal surgery: diagnostic factors and therapy. G Chir 2017; 38:124-129. [PMID: 29205141 PMCID: PMC5726498 DOI: 10.11138/gchir/2017.38.3.124] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Postoperative surgical site infections (SSI) are complication of spinal surgery. These complications may lead to a poor outcome with neurological deficits, spinal deformity and chronic pain. The purpose of this study is to explore the statistical value of diagnostic parameters and the proper therapy. METHOD We retrospectively reviewed 550 patients who underwent spinal instrumentation at our department from January 2011 to December 2015. The SSI was present in 16 patients out of 550 operated. Diagnostic criteria of SSI were the positivity of the surgical wound swab or blood culture, the clinical findings, positivity of laboratory tests and radiological elements. All patients had peri-operative antibiotic prophylaxis. Diagnostic laboratory findings were compared with a homogeneous control group of 16 patients and analyzed by univariate statistical analysis with Chi-square test for the discrete variables. P<0,05 was considered statistically significant. RESULTS Matching the SSI patients with a group of control, fever was not statistically significant for diagnosis as number of leukocytes, neutrophils and lymphocytes. On the contrary values of ESR and CRP were statistically significant with p <0, 01. The hardware was removed only in 3 patients (18%) out of 16 SSI patients. CONCLUSION In this study the statistically significant parameters to diagnose SSI are ESR and CRP values. The leucocytes count, number of lymphocytes and presence of fever integrates the data of ESR and CRP with no statistical significance. Most patients with SSI reach clinical healing with favorable outcome by means of target antibiotic therapy without hardware removal.
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Affiliation(s)
- M. DOBRAN
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - A. MARINI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - M. GLADI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - D. NASI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - R. COLASANTI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - R. BENIGNI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - F. MANCINI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - M. IACOANGELI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
| | - M. SCERRATI
- Neurosurgery Clinic, “Università Politecnica delle Marche”, Ancona, Italy
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A Giant Lumbar Pseudomeningocele in a Patient with Neurofibromatosis Type 1: A Case Report. Case Rep Med 2017; 2017:4681526. [PMID: 28250774 PMCID: PMC5306974 DOI: 10.1155/2017/4681526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/18/2016] [Accepted: 01/16/2017] [Indexed: 11/17/2022] Open
Abstract
This is a rare case of giant lumbar pseudomeningocele with intra-abdominal extension in patient with neurofibromatosis type 1 (NF1). The patient's clinical course is retrospectively reviewed. A 34-year-old female affected by NF1 was referred to our institution for persistent low back pain and MRI diagnosis of pseudomeningocele located at L3 level with paravertebral extension. From the first surgical procedure by a posterior approach until the relapse of the pseudomeningocele documented by MRI, the patient underwent two subsequent posterior surgical procedures to repair the dural sac defect with fat graft and fibrin glue. One month after the third operation, the abdominal MRI showed a giant intra-abdominal pseudomeningocele causing compression of visceral structures. The patient was asymptomatic. The pseudomeningocele was treated with an anterior abdominal approach and the use of the acellular dermal matrix (ADM) sutured directly on the dural defect on the anterolateral wall of the spinal canal. After six months of follow-up the MRI showed no relapse of the pseudomeningocele. Our case highlights the possible use of ADM as an effective and safe alternative to the traditional fat graft to repair challenging and large dural defects.
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