Posterolateral Debridement and Anterior Reconstruction by Limited Spinal Shortening in Thoracic and Lumbosacral Spinal Infections

Abstract

Introduction Anterior debridement and fusion using bone graft or cage is an accepted way of treatment of spinal infections. This can be achieved either through anterior or posterior or two-stage (anterior then posterior) surgery. In last few years, several research works reported good results with use of single posterior surgical approach for treatment of spinal infections. Spinal column shortening may be used in spinal fractures, deformities, and tumors. Since 2004, posterolateral exposure for debridement of thoracic and lumbosacral spinal infections and limited spinal shortening for anterior spinal reconstruction have been used. Patients and Methods A total of 32 patients with spinal infections (10 patients with infection of the thoracic spine and 22 patients with infections of the lumbar spine) were treated by this technique. Patients included 20 males and 12 females with a mean age of 56.3 (range, 20–72) years. Overall, 10 patients had neurological compromise (two Frankel grade A, three Frankel grade B, three Frankel grade C, and two Frankel grade D). Patients are operated under general anesthesia in the prone position through a single posterior exposure. Posterior stabilization by transpedicular screw fixation is performed. A rod is inserted in one side (usually the right side) while the rod in the other side is not inserted to give space sufficient for laminectomy and debridement. For full exposure of the anterior aspect of the vertebral bodies in the thoracic spine, excision of the medial 5 cm of one or two ribs may be performed. In the lumbar spine, dissection around the vertebral body is not needed as retraction of the cauda equine usually gives good space sufficient for curettage of the disc and debridement of the infected tissues and the technique is posterior lumbar interbody fusion (PLIF). Infected material is curetted and the second rod is inserted. Reconstruction of the anterior column is achieved by limited spinal shortening while carefully observing the dura for kinking. Then, posterior fusion is performed using local bone graft obtained from the laminae and ribs. Results Patients were followed up for a mean of 33 (range, 6–80) months. Causative organisms were TB in 20 patients, Staph aureus in 4 patients, salmonella typhi, 1 patient, brucella in 1 patient, and bacteriologic testing of intraoperative samples did not find germs in 6 patients. Operative time ranged between 100 and 190 (mean 135) minutes. Successful fusion was achieved in all patients 3 to 6 months postoperatively. Neurological recovery to Frankel grade E was obtained in all but four patients (three Frankel grade D and one Frankel grade B). Five complications were encountered; malpositioned pedicle screw, deep venous thrombosis (DVT), delayed wound healing, kyphosis progression, and temporary neurological deterioration. No active infection occurred till the end of follow-up. Conclusion Posterolateral debridement and anterior reconstruction by limited spinal shortening is an alternative method for surgical treatment of spinal infections. Advantages of this technique include a wide cancellous surface for bone healing, good stability, avoid the morbidity of bone graft harvesting, short operative time, and less morbidity.