Abstract
BackgroundPyogenic spondylodiscitis represents a potentially life-threatening condition. Due to the low incidence, evidence-based surgical recommendations in the literature are equivocal, and the treatment modalities remain controversial.Case presentationA 59 year-old patient presented with a history of thoracic spondylodiscitis resistant to antibiotic treatment for 6 weeks, progressive severe back pain, and a new onset of bilateral lower extremity weakness. Clinically, the patient showed a deteriorating spastic paraparesis of her lower extremities. An emergent MRI revealed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression, paravertebral and epidural abscess, and signs of myelopathy. The patient underwent surgical debridement with stabilization of the anterior column from T6–T9 using an expandable titanium cage, autologous bone graft, and an anterolateral locking plate. The patient recovered well under adjunctive antibiotic treatment. She presented again to the emergency department 6 months later, secondary to a repeat fall, with acute paraplegia of the lower extremities and radiographic evidence of failure of fixation of the anterior T-spine. She underwent antero-posterior revision fixation with hardware removal, correction of kyphotic malunion, evacuation of a recurrent epidural abscess, decompression of the spinal canal, and 360° fusion from T2–T11. Despite the successful salvage procedure, the patient deteriorated in the postoperative phase, when she developed multiple complications including pneumonia, acute respiratory distress syndrome, bacterial meningitis, abdominal compartment syndrome, followed by septic shock with multiple organ failure and a lethal outcome within two weeks after revision surgery.ConclusionThis catastrophic example of a lethal outcome secondary to failure of anterior column fixation for pyogenic thoracic spondylodiscitis underlines the notion that surgical strategies for the infected spine must be aimed at achieving absolute stability by a 360° fusion. This aggressive – albeit controversial – concept allows for an adequate infection control by adjunctive antibiotics and reduces the imminent risk of a secondary loss of fixation due to compromises in initial fixation techniques.
Highlights
Spinal infections are rare and the annual incidence of spondylodiscitis is estimated to be about 2.4/100,000 person-years [1]
Most recommendations for surgical treatment of spinal infections are largely based on retrospective case series or case reports and remain inconsistent [7,8]
We present the catastrophic example of a 59-year old patient with inadequate initial fixation for thoracic spondylodiscitis, with a fatal outcome two weeks after revision surgery with 360° thoracic spine fusion
Summary
The dismal outcome of this 59-year patient, secondary to revision fixation for a failed anterior fusion for pyogenic thoracic spondylodiscitis, implies that an inadequate initial treatment modality may lead to a delayed cascade of complicating events with the potential for a lethal outcome. We recommend the more aggressive approach – which is supported by the recent peer-reviewed literature – of a radical surgical debridement associated with a 360° antero-posterior instrumented fusion, for multi-morbid patients suffering from pyogenic spondylodiscitis. Written informed consent was obtained from the patient's relatives for publication of this case report
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