Lumbar Pyogenic Spondylodiscitis Research Articles

Lateral Approach With and Without Posterior Stabilization for Lumbar Pyogenic Spondylodiscitis Treatment: A Retrospective Study With an Average Follow-up of 7 Years

Objective: The aim of this study was to present the results after an average of 7-year follow-up in patients diagnosed with pyogenic spondylodiscitis (PS) treated with lumbar discectomy and fusion through minimally invasive lateral lumbar interbody fusion (LLIF), with and without posterior stabilization.Methods: In this retrospective analysis, patients diagnosed with PS treated with minimally invasive LLIF were studied. Variables included C-reactive protein (CRP), blood cultures, and findings on magnetic resonance imaging, computed tomography, and x-ray examinations. The classification of PS according to Pola was recorded.Results: Twenty-one patients were male (70%) and 9 were female (30%), with an average age of 67.6 years (range, 33–85 years). The average follow-up was 83.2 months (range, 12–160 months). In 7 out of the 30 cases, treatment consisted exclusively of discectomy and anterior fusion through LLIF. Bone consolidation was observed in 27 out of 30 cases (90%), with an average postoperative CRP level of 5.77±5.00 mg/L at the end of follow-up.Conclusion: The treatment of lumbar PS through debridement and minimally invasive LLIF, with or without posterior stabilization, resulted in infection control over an average follow-up of 83 months.

In Reply to the Letter to Editor Regarding “Management of Lumbar Pyogenic Spondylodiscitis in Germany: A Cross-Sectional Analysis of Spine Specialists”

In Reply to the Letter to Editor Regarding “Management of Lumbar Pyogenic Spondylodiscitis in Germany: A Cross-Sectional Analysis of Spine Specialists”

Letter to Editor Regarding “Management of Lumbar Pyogenic Spondylodiscitis in Germany: A Cross-Sectional Analysis of Spine Specialists”

Letter to Editor Regarding “Management of Lumbar Pyogenic Spondylodiscitis in Germany: A Cross-Sectional Analysis of Spine Specialists”

Efficacy of Minimally Invasive Oblique Lumbar Interbody Fusion Using Polyetheretherketone Cages for Lumbar Pyogenic Spondylodiscitis Treatment.

(1) Background: This study evaluated the efficacy and safety of a minimally invasive oblique lumbar interbody fusion (OLIF) using polyetheretherketone (PEEK) cages for the treatment of lumbar pyogenic spondylodiscitis. (2) Methods: Fifty-one patients with single-level lumbar pyogenic spondylodiscitis were included in the study. Patients were divided into two groups: anterior lumbar interbody fusion with a tri-cortical iliac bone graft (ALIF+ tri-cortical iliac bone graft) (n = 28) and OLIF using PEEK cages with an autologous bone graft (OLIF+ PEEK cages) (n = 23). Perioperative radiographic parameters, complications, and clinical outcomes in both groups were analyzed and compared. (3) Results: The postoperative and final follow-up LL (lumbar lordosis) and RL (regional lordosis) were improved in both groups (p < 0.001). But, compared with the ALIF group, the OLIF group had more improvement of the RL. The operation time was 79 min for the OLIF group and 101 min for the ALIF group (p < 0.05). The intraoperative blood loss was 92 mL for the OLIF group and 114 mL for the ALIF group (p < 0.05). Significant clinical improvement was observed in visual analogue scale scores for the back and Oswestry Disability Index in both groups (p < 0.001). There was no recurrence of infection. (4) Conclusions: Compared with the ALIF group, the OLIF group had more improvement in radiographic and clinical outcomes. Thus, OLIF using PEEK cages with an autologous bone graft could be proposed for the surgical treatment of lumbar pyogenic spondylodiscitis.

Safety and Efficacy of Polyetheretherketone (PEEK) Cages and Cadaveric Allografts in Transforaminal Lumbar Interbody Fusion (TLIF) for Treating Lumbar Pyogenic Spondylodiscitis.

There have been many studies in the operative management of pyogenic spondylodiscitis with foreign materials. However, it still remains an issue of debate on whether the allografts may be used in pyogenic spondylodiscitis. This study sought to evaluate the safety and effectiveness of PEEK cages and the cadaveric allograft in transforaminal lumbar interbody fusion (TLIF) for treating lumbar pyogenic spondylodiscitis. From January 2012 to December 2019, 56 patients underwent surgery for lumbar pyogenic spondylodiscitis. The posterior debridement of all patients and their fusion with allografts, local bone grafts, and bone chip cages were performed before posterior pedicle screw fusion. An assessment of the residual pain, the grade of neurological injury, and the resolution of infection was conducted on 39 patients. The clinical outcome was evaluated using a visual analog scale (VAS) and the Oswestry Disability Index (ODI), and neurological outcomes were appraised based on Frankel grades. The radiological outcomes were evaluated via focal lordosis, lumbar lordosis, and the state of the fusion. Staphylococcus aureus and Staphylococcus epidermidis were the most common causative organisms. The mean preoperative focal lordosis was -1.2° (-11.4° to 5.7°), and the mean postoperative focal lordosis increased to 10.3° (4.3°-17.2°). At the final follow-up, there were five cases with subsidence of the cage, no case of recurrence, and no case with cage and screw loosening or migration. The mean preoperative VAS and ODI scores were 8.9 and 74.6%, respectively, and improvements in VAS and ODI were 6.6 ± 2.2 and 50.4 ± 21.3%, respectively. The Frankel grade D was found in 10 patients and grade C in 7. Following the final follow-up, only one patient improved from Frankel grade C to grade D while the others recovered completely. The PEEK cage and cadaveric allograft combined with local bone grafts is a safe and effective choice for intervertebral fusion and restoring sagittal alignment without increased incidence of relapse for treating lumbar pyogenic spondylodiscitis.

Management of Lumbar Pyogenic Spondylodiscitis in Germany: A Cross-Sectional Analysis of Spine Specialists

The incidence of pyogenic spondylodiscitis is increasing, and the disease is associated with considerable morbidity, mortality, long-term healthcare utilization and societal costs. Disease-specific treatment guidelines are lacking and there is little consensus regarding optimal conservative and surgical management. This cross-sectional survey of German specialist spinal surgeons sought to determine practice patterns and degree of consensus regarding the management of lumbar pyogenic spondylodiscitis (LPS). An electronic survey covering provider information, diagnostic approaches, treatment algorithms, and follow-up care of patients with LPS was distributed to members of the German Spine Society. Seventy-nine survey responses were included in the analysis. Magnetic resonance imaging is the diagnostic imaging modality of choice for 87% of respondents; 100% routinely measure C-reactive protein in suspected LPS and 70% routinely take blood cultures before therapy initiation; 41% believe that surgical biopsy to obtain microbiological diagnosis should be carried out in all cases of suspected LPS, whereas 23% believe that surgical biopsy should only be carried out when empirical antibiotic therapy proves ineffective; 38% believe an intraspinal empyema should always be surgically evacuated, regardless of spinal cord compression. The median intravenous antibiotic duration is 2weeks. The median total duration of the antibiotic therapy (intravenous and oral) is 8weeks. Magnetic resonance imaging is the preferred imaging modality for follow-up of both conservatively and operatively treated LPS. There exists considerable variation of care in the diagnosis, management, and follow-up of LPS among German spine specialists with little agreement on key aspects of care. Further research is required to understand this variation in clinical practice and to enhance the evidence base in LPS.

Clinical results of a lamina with spinous process and an iliac graft as bone grafts in the surgical treatment of single-segment lumbar pyogenic spondylodiscitis: a retrospective cohort study

BackgroundA retrospective study compared the results of a lamina with spinous process (LSP) and an iliac graft (IG) as bone grafts in single-segment lumbar pyogenic spondylodiscitis (LPS) through one-stage-posterior-only approach with radical debridement and instrumentation.MethodsA LSP was placed in 17 patients (group A), and an IG was implemented in 20 patients (group B). The surgery time, surgery hemorrhage, hospital stay, drainage, and follow-up (FU) were recorded and compared. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, visual analogue scale (VAS), Oswestry Disability Index (ODI), segmental angle, intervertebral height and bony fusion time were compared preoperatively and at the final FU.ResultsAll patients were followed-up for a mean of 27.94 ± 2.35 months in group A and 30.29 ± 1.89 months in group B, without a difference. The mean age was younger in group A than in group B (P < 0.05). The surgery time, surgery hemorrhage, and hospitalization cost were lower in group A than in group B (P < 0.05), except for the hospital stay and drainage time. 10 patients in group A had fever and 12 patients in group B. The ESR, CRP level, VAS and ODI scores were significantly decreased, and no significant differences were found between the groups at the final FU. The distribution of bacterial agents in blood culture was 1 case of Aerobacter cloacae, 2 of Staphylococcus aureus, 2 of Escherichia coli, and 1 of Streptococcus viridis in group A and 1 of S. aureus, 1 of Staphylococcus warneri and 2 of Klebsiella pneumoniae in group B. Pyogenic infection was observed in the pathological findings of all patients. No significant difference was found in the mean segmental angle or mean intervertebral height preoperation and at the final FU.ConclusionThe use of LSP could be an effective bone grafting for surgical management for the LPS while surgery is proposed as a good management strategy for single-segment LPS in carefully selected patients.

Single-stage debridement via autogenous iliac bone graft through the OLIF corridor and lateral fixation in treating spontaneous single-level lumbar pyogenic spondylodiscitis

BackgroundThe aim of the present study was to investigate the efficacy and safety of mini-open oblique debridement and lumbar interbody fusion combined with lateral screw fixation for treating single-level pyogenic spondylodiscitis.MethodsTwelve patients with single-level lumbar pyogenic spondylodiscitis underwent OLIF combined with lateral screw fixation were analyzed. Patients underwent follow-up for 12 to 24 months. The clinical characteristics, etiological examinations, operative time, intraoperative blood loss, Oswestry Disability Index (ODI), visual analog scale score (VAS), postoperative complications, and the bony fusion rate were recorded.ResultsThe mean follow-up period of time was 14.8 months. The average operative time and intra-operative blood loss were 129.0 ± 19.76 min and 309.2 ± 92.96 mL, respectively. No severe intra-operative complications were observed during surgery, except in 1 case that develops abdominal pain and distension after surgery, 2 cases that develop left-sided transient thigh pain/numbness and 8 cases that complains of donor site (iliac crest) pain. All of these symptoms disappeared 8 weeks after surgery. Tissue sample cultures were obtained from all patients intraoperatively and four (33.3%) were positive, including 2 with Staphylococcus aureus, 1 with Staphylococcus epidermidis, and 1 with Escherichia coli. During an average of 22.5 ± 2.1 days (range, 14–29 days) after surgery, WBC, CPR, and ESR levels in all patients had returned to normal. All patients were pain free with no recurring infection. Solid bony fusions were observed in all cases within 6 months, including 10 with I grade fusion, 2 with II grade fusion according to the classification suggested by Burkus et al. No fixation failure was observed during follow up and solid bony fusions were observed in all 12 patients at finally follow-up. A significant postoperative increase was also observed in the mean segmental height and lordosis (P < 0.05), followed by a slight decrease of segmental height and lordosis at final follow-up. At the final follow up, the mean VAS (1.5 ± 0.6) and ODI (18.9 ± 7.6) were significantly lower than VAS (8.4 ± 2.7) and ODI (71.2 ± 16.5) before surgery (P < 0.01).ConclusionSingle-stage debridement with autogenous iliac bone graft through the OLIF corridor and lateral fixation was a feasible surgical approach in our consecutive 12 cases of pyogenic spondylitis.

Outcome of one-stage percutaneous endoscopic debridement and lavage combined with percutaneous pedicle screw fixation for lumbar pyogenic spondylodiscitis.

This study assessed the therapeutic effect of one-stage percutaneous endoscopic debridement and lavage (PEDL) combined with percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar pyogenic spondylodiscitis. From March 2017 to October 2019, 51 patients diagnosed with pyogenic spondylodiscitis underwent PPSF followed by PEDL in our department. Biopsy specimens were examined for microorganisms and evaluated histopathologically. Clinical outcomes were assessed by physical examination, routine serological testing, visual analogue scale (VAS), Oswestry Disability Index (ODI) and imaging studies. Of the enrolled patients, the operation time ranged from 90 min to 114 min every level with an average of 102 min, and the average drainage time ranged from 6 days to 10 days with an average of 7.4 days. All patients who complained of lower back pain symptoms were more relieved than before surgery. Causative pathogens were identified in 20 of 51 biopsy specimens; Staphylococcus aureus was the most prevalent. However, there were eight patients with postoperative complications. The mean follow-up was 25.0 ± 3.8 (range: 20-32) months. Inflammatory markers showed that infection was controlled. The VAS and ODI improved significantly. At the last follow-up, magnetic resonance imaging showed that the infected lesions had disappeared. PEDL supplementing PPSF may be useful for patients with single-level lumbar pyogenic spondylodiscitis, as it is minimally invasive, especially for patients who cannot undergo conventional open surgery due to poor health or advanced age.

Is It Appropriate to Insert Pedicle Screws at an Infected Vertebral Body in the Treatment of Lumbar Pyogenic Spondylodiscitis?

Is It Appropriate to Insert Pedicle Screws at an Infected Vertebral Body in the Treatment of Lumbar Pyogenic Spondylodiscitis?

Early surgical debridement and fixation for pyogenic lumbar spondylodiscitis

BackgroundManagement of pyogenic lumbar spondylodiscitis still represent a major conflict and challenge in neurosurgery due to different pathogens and the different methods available for management.ObjectiveThe aim of this study was to evaluate the outcome of posterior lumbar spinal fixation with debridement as a treatment modality in the management of pyogenic lumbar spondylodiscitis.Patients and methodThis is a prospective study conducted on patients presenting to the Neurosurgery Department of Cairo University hospitals diagnosed to have either spontaneous or iatrogenic pyogenic lumbar spondylodiscitis. All cases were operated upon by surgical debridement, drainage, and posterior lumbar fixation in the same setting. Antibiotics were prescribed according to the obtained culture and sensitivity. Laboratory follow-up was done to all patients. Clinical outcome was evaluated in terms of the Denis Functional Pain Scale. Follow-up period ranged from 5 to 14 months.ResultsA total of 25 patients comprised of 15 males and 9 females with a mean age of 45.7 years (range 32–63 years) were included in this study. Nine cases had a previous lumbar discectomy surgery, and 15 cases presented with spontaneous spondylodiscitis. L4–5 level was the most frequent site of pyogenic discitis. Excellent outcome and good outcomes (score 1–3 in Denis Functional Pain Scale) were reported in 84% of the patients and poor outcomes (score 4–5) in 16%.ConclusionSurgical fixation and debridement can be considered as an effective modality in the management of pyogenic lumbar spondylodiscitis with early ambulation, good control of pain, and early hospital discharge.

A rare lumbar pyogenic spondylodiscitis caused by staphylococcus caprae with initial misdiagnosis: case report and literature review

BackgroundStaphylococcus caprae (Sc) is an uncommon causative organism for human. Lumbar pyogenic spondylodiscitis (LPS) of Sc is extremely rare and only a few cases have been reported. As far as we know, there is no specific literature on the diagnosis and treatment for LPS of Sc with L5 nerve root irritation.Case presentationA 65-year-old male patient complained of chronic low back pain for 10 years, acute worsening with radiating pain to left lower extremity over a month. Physical examination revealed tenderness point on his low back, 3/5 dorsiflexor strength in his left 1st toe and decreased sensation of pin prick over the left lateral shank and medial dorsal foot. The individual was initially misdiagnosed with lumbar disc herniation (LDH) without further examination in outpatient, which was then found to be LPS of Sc with L5 nerve root irritation after admission to our hospital. Magnetic resonance images (MRI) of lumbar spine exhibited inflammation signal at L4-L5 level of the vertebral body and disc with hypointense on T1-weighted images (T1-WI) and hyperintense on T2-weighted images (T2-WI). The causative organism was confirmed by the culture of irrigation fluid obtained from L5 vertebrae by needle puncture. After systemic conservative treatment including using sensitive antimicrobial agents and immobilization, the rare infection was finally cured. The patient also showed a satisfactory recovery during the 36-month follow-up period.ConclusionsConfirming the diagnosis and identifying the causative organism as soon as possible is the key point for the treatment of LPS. LPS of Sc causing nerve root irritation is rare but curable with early diagnosis and proper therapy. The culture of irrigation fluid obtained from vertebrae by needle puncture may be an effective and sensitive attempt for potential infection of spine to identify the causative organism at early stage of the disease.

Application of oblique lumbar interbody fusion for lumbar intervertebral pyogenic infection

Objective To investigate the safety, key techniques and clinical efficacy of OLIF (oblique lumbar interbody fusion) corridor combined with lumbar intervertebral debridement, fusion with two interbody and internal fixation for the treatment of single-level lumbar pyogenic spondylodiscitis. Methods From February 2016 to March 2017, data of 12 patients with single-level lumbar intervertebral pyogenic infection diagnosed in our hospital who had undergone oblique lumbar interbody fusion with two interbody and posterior pedicle screw fixation via Wiltse approach were retrospectively analyzed. Among them, there were 10 males and 2 females, aged from 49 to 79 years, with an average age of 65.4±9.5 years. The white blood cells (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded and analyzed before operation and at the last follow-up. Lumbar pain was assessed by visual analogue acale (VAS), Oswestry disability index (ODI), and clinical efficacy was assessed by the MOS 36-item short-form health survey (SF-36) and Kirkaldy-Willis criteria. The hospitalization time, operation time, intraoperative blood loss, pathological reports, etiological results and complications were recorded. Disc height (DH), segmental angle (SA) and Lumbar Lordosis (LL) were measured before operation and at the last follow-up. The fusion time was recorded. Paired t-test and ANOVA was used for data analysis. Results All patients underwent surgery successfully, including 6 cases using two titanium meshes and 6 cases using two autologous tricortical iliac bones. Pathogenic culture was positive in 10 cases, with a positive rate of 83.3%, including 4 cases of streptococcus, 4 cases of Staphylococcus aureus, 1 case of Escherichia coli, and 1 case of Klebsiella pneumoniae. All patients were followed up for 16.1±5.1 months. At the last follow-up, WBC ([6.25±2.02] ×109/L) was lower than that before operation ([4.89±1.28] ×109/L), CRP (preoperation 58.73±52.56 mg/L vs postoperation 8.48±8.79 mg/L) and ESR (preoperation 51.88±19.04 mm/1 h vs postoperation 9.25±5.50 mm/1 h) were significantly lower (P< 0.01). The VAS score was preoperation 6.67±1.63 and postoperation 1.50±0.55, ODI score was preoperation 72.57%±3.41% and postoperation 18.00%±2.31%, and both were significantly lower postoperatively (P < 0.01). SF-36 score (preoperation 56.33±4.93 vs postoperation 73.73±5.86) was significantly higher (P< 0.01) respectively. The postoperative height of intervertebral space ([11.68±2.64] mm) was significantly higher than that before operation ([5.18±1.58] mm). The disc height at the last follow-up was (11.22±2.25) mm, and the loss rate was 1.89% compared with that of the immediate postoperatively; The postoperative lumbar lordosis angle (32.89°±14.52°) was significantly increased compared with that of the preoperative (24.16°±13.49°), and maintained well at the last follow-up (32.27°± 14.21°); The postoperative segmental angle (10.8°±8.51°) was significantly increased compared with that of the preoperative (5.81°±7.44°), and maintained well at the last follow-up (9.94°±7.87°). The fusion time ranged from 6 to 16 months, with an average of 9.2±3.5 months. The clinical efficacy was excellent in 10 cases (83.3%) and good in 2 cases (16.7%). The excellent and good rate was 100%. One case of pulmonary infection and pulmonary embolism occurred 2 days after operation, and recovered after use of antibiotics and anticoagulation treatment in ICU; one case of intramuscular venous thrombosis was found 1 day after operation, and recovered after anticoagulation treatment; no loosening of internal fixation was found, and no complications related to OLIF corridor occurred. Conclusion The treatment of single-level lumbar intervertebral pyogenic infection with OLIF corridor combined with lumbar intervertebral debridement, fusion with two interbody and internal fixation has the advantages of less blood loss, shorter operation time, more direct clearance of intervertebral space and left paravertebral focus, no disturbance of intraspinal canal and posterior structure, higher positive rate of etiology detection, shorter bedrest time and better restore of disc height and lumbar lordosis after operation. What’s more, the fusion rate is high and the clinical efficacy is satisfactory. Key words: Lumbar vertebrae; Infection; Spinal fusion

One-stage Debridement via Oblique Lateral Interbody Fusion Corridor Combined with Posterior Pedicle Screw Fixation in Treating Spontaneous Lumbar Infectious Spondylodiscitis: A Case Series.

ObjectiveSurgery is indicated when antibiotic treatment fails in pyogenic spondylodiscitis, which is caused by pathogens such as the Staphylococcus species. The aim of the present study was to investigate the efficacy and safety of the oblique lateral interbody fusion (OLIF) corridor approach combined with posterior pedicle screw fixation for treating pyogenic spondylodiscitis.MethodsThis was a retrospective case series study. A total of 11 patients with an average age of 60.7 years (range, 40–70 years; 10 males and 1 females) with lumbar pyogenic spondylodiscitis who underwent single‐stage debridement and reconstruction using the OLIF corridor combined with posterior pedicle screw fixation were recruited in our study from June 2016 to July 2017. All patients had single‐level pyogenic spondylodiscitis between T12 and L5. The baseline data, perioperative outcomes (operative time, intra‐operative blood loss, and intra‐operative complication), postoperative laboratory tests (erythrocyte sedimentation rate [ESR], C‐reactive protein [CRP], white blood count [WBC], and tissue culture results), long‐term complications (recurrence, fixation failure, and bony non‐fusion rates), and duration of antibiotic administration were reviewed. Outcomes evaluated using a variety of scales including visual analog scale (VAS) score and Oswestry disability index (ODI), were compared pre‐operatively and post‐operatively.ResultsThe mean follow‐up period of time was 18.3 months. The average operative time and intra‐operative blood loss were 217.0 ± 91.91 min and 220.9 ± 166.10 mL, respectively. There were no intra‐operative complications, except in 1 patient who encountered somatosensory evoked potentials changes and 1 patient who had motor evoked potentials changes, both without post‐surgery neurological deficits. Causative organisms were identified in 4 patients: Staphylococcus aureus in 1 patient and Streptococcus in 3 patients. At approximately 8.8 weeks after surgery, WBC, CRP, and ESR had returned to normal levels. All patients were pain free with no recurring infection. There was no fixation failure during follow up. Solid bony fusions were observed in all cases within 6 months. At the final follow up, the mean VAS (0.6 ± 0.69) and ODI (14.4 ± 4.27) were significantly lower than those before surgery (P < 0.05).ConclusionOne‐stage debridement with autogenous iliac bone graft through the OLIF corridor combined with posterior pedicle screw fixation is effective and safe for single‐level spontaneous lumbar pyogenic spondylodiscitis after antibiotic treatment fails.

Continuous Epidural Irrigation and Drainage Combined with Posterior Debridement and Posterior Lumbar Inter-Body Fusion for the Management of Single-Segment Lumbar Pyogenic Spondylodiscitis.

Purpose: To observe the clinical curative effect of continuous epidural irrigation combined with posterior debridement and posterior lumbar inter-body fusion with instrumentation for the therapy of single-segment lumbar pyogenic spongdylodiscitis. Methods: From June 2010 to November 2013, surgical treatment was performed in 18 patients with pyogenic spondylodiscitis. The surgical indications were progressive biomechanical instability, epidural abscesses, deterioration of neurologic status, and intractable back pain. All these patients received posterior decompression with posterior instrumentation, debridement of infected tissue, and inter-body fusion. Visual Analogue Scale (VAS) scores were used to assess clinical outcomes. The neural function was evaluated by the Frankel grading system. Laboratory and radiologic results were recorded during clinical follow-up for at least one year. Results: The average follow-up period was 18 months after the operation. The VAS scores decreased from an average of 7.1 points before the procedure to 2.6 points after operation. The neurologic deficits of all the patients were recovered to Frankel grade E. All of the examined laboratory parameters were normalized gradually. Imaging-documented fusion was achieved in each patient, and no implants failure was noted. No patients showed any evidence of recurrence or persistence of infection. Conclusion: In carefully selected patients, single-segment lumbar pyogenic spondylodiscitis can be cured successfully with continuous epidural irrigation and drainage combined with posterior debridement and posterior lumbar inter-body fusion. Instrumentation could provide immediate stability and reconstruction of the spine column, and the presence of instrumentation did not result in any persistence or recurrence of infection. Continuous epidural irrigation and drainage is an effective method facilitating the elimination of residual infection.

Transforaminal Lumbar Interbody Fusion with Antibiotics Delivered by CaSO4 Drug Carrier System for Pyogenic Spondylodiscitis

Spondylodiscitis is a challenging spinal disorder that requires surgical treatment only as a last resort. The use of various procedures and instruments remains controversial. In this retrospective study, we reported the safety and efficacy of a CaSO4 drug carrier system for the transforaminal lumbar interbody fusion (TLIF) procedure for lumbar pyogenic spondylodiscitis. Thirty-four patients with lumbar spondylodiscitis underwent TLIF. CaSO4 beads carrying vancomycin and gentamycin were implanted in the trajectory of screws and disc spaces. We measured markers of inflammation, scores of neurologic recovery, and quality of life. The fusion status was assessed at final follow-up and the correction of local and total lordotic angle was calculated. The patients were followed up for at least 12 months (range, 12-24 months). At 3 months follow-up, C-reactive protein levels and erythrocyte sedimentation rate returned to normal with no relapse. Nineteen patients with American Spinal Injury Association grade D preoperatively returned to American Spinal Injury Association grade E. The improvement on the visual analog scale and Oswestry Disability Index was 66.9% and 84.9%, respectively. At 12 months follow-up, 67.6% of patients achieved definitive union. The corrections of total and local lordotic angle were 10.02° ± 8.77° and 7.7° ± 8.75°, respectively. The rate of achievement of satisfactory Kirkaldy-Willis functional criteria was 85.3%. The combined use of single-level TLIF with a CaSO4 drug delivery system was safe and effective for treatment of pyogenic lumbar spondylodiscitis. The system promoted reduction of inflammation with limited fixed segments without a negative impact on fusion status. This procedure may be considered a novel choice for spondylodiscitis, with more efficacy and less invasion.

Minimally invasive surgery for the treatment of thoraco lumbar pyogenic spondylodiscitis: indications and outcomes.

Pyogenic spondylodiscitis (PS) is a non-specific infection affecting intervertebral disks and adjacent vertebral bodies. Once considered a rare condition in developed countries, the incidence of PS has been increasing alarmingly and still represents a challenge for clinicians and orthopedic surgeons. New minimally invasive techniques have been proposed but the proper indications for these different approaches remain controversial. The aim of this study was to describe the available minimally invasive surgical techniques and to evaluate their proper indications through a review of recent literature. Over 30 articles of recent scientific literature have been reviewed and analyzed. Studies were searched through the PubMed database using the key words: spondylodiscitis, minimally invasive, and surgical treatment. The most interesting and valid techniques and results have been reported. Despite the exclusion of case reports, all the available studies have been conducted on small groups of patients. Indications for each technique have been reported according to a clinical-radiological classification of PS. Six of the most widely used minimally invasive surgical techniques have been described. High success rates have been reported in terms of preventing the progression of spondylodiscitis into more destructive forms, reduction of time and operative hospitalization, faster pain relief, early mobilization, and achievement of microbiological diagnosis. The role of minimally invasive surgery in the treatment of PS is rapidly expanding. Reducing surgery-related morbidity in these frail patients is possible and often necessary. However, while more and more new techniques are being proposed, still few clinical data are available. Clinical comparison studies with open traditional surgery should be encouraged, and more attention should be paid to long-term outcomes. For the present, the indications for minimally invasive procedures should, therefore, be evaluated on a case by case basis and on clinical and radiological findings.

Outcome of Transforminal Lumbar Thorough Debridement, Decompression, and Spondylodesis Technique in Treatment of 25 Patients with Pyogenic Spondylodiscitis

Lumbar pyogenic spondylodiscitis (LPS) is still a tangled problem in its management, especially with increasing rates of cases who underwent different spinal procedures and in patients with chronic medical disease. One-stage posterior direct transforminal lumbar thorough debridement of septic lesion, decompression, and spondylodesis (TLTDDS) are the main goals in treatment of complicated LPS without additional morbidity of anterior surgery. This is a retrospective assessment of the clinical, laboratory, functional, and radiologic outcomes in 25 patients with LPS who underwent the TLTDDS procedure. Twenty-nine patients with complicated LPS were treated surgically by TLTDDS surgery from January 2014 to August 2017. Complete records of 25 patients were available for evaluation. All patients were examined clinically for back or leg pain using a visual analog scale (VAS) and neurological assessment by the American Spine Injury Association. Perioperative outcome and complications were documented. All patients were serially followed up between 12 and 32 months as regard pain (VAS), functional status by Kirkaldy Willis criteria, and Oswestry disability index, laboratory, and radiologic outcomes (angle of segmental kyphosis, lumbar lordosis correction, and fusion criteria). Definitive solid bony fusion was seen between 6 and 14 months, except in 3 cases, which showed probable fusion. There was significant improvement in VAS, American Spine Injury Association index, laboratory investigations, and Oswestry disability index. One patient (5%) had transient neurological deficit, which resolved completely within 2 months. TLTDDS surgery is an effective procedure in the treatment of symptomatic LPS and allows abscess evacuation with adequate neural decompression, segmental kyphosis correction, and functional improvement.

Minimally invasive spine surgery in the treatment of pyogenic spondylodiscitis: an initial retrospective series study.

IntroductionPyogenic spondylodiscitis is a bacterial infection affecting the intervertebral disc and its adjacent vertebrae. Although relatively rare, it is a challenging medical disease with a poor prognosis that requires immediate diagnosis and treatment with suitable antibiotics.AimTo evaluate the clinical outcome of minimally invasive spine surgery (MIS) for pyogenic spondylodiscitis.Material and methodsThe retrospective study cohort consisted of 10 consecutive patients who had undergone MIS decompression and/or discectomy for thoracic or lumbar pyogenic spondylodiscitis in our hospital. Data including patient characteristics, symptoms, visual analog scale (VAS) score, surgical approach and postoperative outcomes were obtained for retrospective analysis.ResultsBetween January 2005 and December 2013, 10 patients underwent MIS decompression in the Department of Orthopedics in our medical university. Seven of these patients had lumbar infections and 3 had thoracic infections. All 10 patients had improved VAS scores immediately after surgery and after discharge. The VAS score (respectively on postoperative day 1 and day 7) suggested that the patients in this study had significantly less pain than preoperatively (day 1: 5 vs. 9, p < 0.001; day 7: 2.9 vs. 9, p < 0.001). The organism was obtained in 10 (100%) patients by the operative cultures. All patients achieved an excellent clinical recovery without the need for further spine surgery. All patients underwent postoperative imaging during follow-up and showed complete resolution or dramatically improved magnetic resonance imaging changes.ConclusionsMinimally invasive spine surgery is a safe and effective surgical approach for pyogenic spondylodiscitis.

Supplemental Antibiotic Injections into the Disc Eradicate Lumbar Pyogenic Spondylodiscitis and Reduce Residual Lumbago

The standard treatment for lumbar pyogenic spondylodiscitis is an intravenous antibiotic. If conservative treatment fails, surgery is indicated. However, many patients suffer from residual lumbago after prolonged conservative treatment, and invasive surgery is problematic in poorly conditioned patients. We developed a new treatment in which intravenous antibiotics are supplemented by multiple injections of antibiotic directly into the infected disc. Here we report our experience with twenty adult patients. Shortly after infection was diagnosed, we performed the needle biopsy that we reported followed by direct antibiotic injection into the infected disc. Antibiotic was injected twice weekly until inflammation subsided. The average number of injections was 6.8. Infection was eradicated in all cases. Surgery was needed in two cases (10%): one because of acute paralysis and one because of residual sciatica. We observed no adverse effects. Excluding two cases who died of cancer, we obtained excellent (n=12) or good (n=3) results (83%) in a total of 18 patients evaluated according to Macnab's lumbago criteria at an average of 27.5 months follow-up. The disc height was retained in ten cases during the initial two months of treatment: nine of these patients showed excellent results on Macnab's lumbago scale. We conclude that supplementing standard systemic antibiotic therapy with multiple injections of antibiotic directly into the infected disc provides a safe and effective method of eradicating lumbar pyogenic spondylodiscitis. This treatment also provides an excellent chance of maintaining the disc height, which leads to less residual lumbago.